GOVERNMENT OF PAKISTAN UNITED NATIONS POPULATION FUND

PAKISTAN POPULATION ASSESSMENT
JANUARY 2003

Executive Summary

The Country Population Assessment 2003 presents a situation analysis of Pakistan’s 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 women’s 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 women’s 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 90’s. 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 stakeholders–government 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 60’s. 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 women’s 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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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.14-APR-03 . However as mentioned in the population policy of Pakistan. fertility and poverty. 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. 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. STIs and AIDs. Undoubtedly unattended population pressures are likely to contribute to the creation of disastrous social and political environment in the country. Financial resources allocated to the population and health sectors by the Government have risen. Furthermore. PAGE 3 O F 95 . in seeking care during pregnancy and delivery and in the recognition of symptoms and treatment of RTIs. Pakistan requires support to achieve replacement level fertility by 2020.5 billion requirements are estimated for the next 19 years for achieving the fertility replacement.49.obstacles to using family planning. Rs.

2001. Estimate. UNICEF PRHFPS op.5% 43% 19% 3. PIHS – Round IV. 20002001.2002 Pakistan Reproductive Health and Family Planning Survey.7% 33.cit.16% 32.0% 97.000-80. 2001 Ibid Ibid Ibid Ibid Ec.1% 34.69% 2. Ibid Ibid 1998 Census Report of Pakistan. See Chapter 3.3% 93. PRHFPS op.6% 39.77 3. Govt of Pakistan. Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid PAGE 4 O F 95 .5% 108/100 63 yrs 82/1000 lb 103/1000 lb 300-700/100. 2002. 2001-2002.000 Year Source 2002 1981-98 2002 1998 1998 1998 1998 1998 2001 2001 2000 2002 2000 2001 2000 2000 2002 2002 Economic Survey.14-APR-03 . op. of Pakistan.cit.000 lb 77% 19% 51% 28% 1.7% 21.40 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 PRHFPS op.0% 30. Govt. NIPS.67 5. cit Ibid UNAIDS UNAIDS 95. Surv.4% 4. cit.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 2.9% 27.800 70.

A Note on Statistics and Figures Key statistics on population. mostly taken from the official government documents. This is due to the use of different source of data which has been quoted as well.14-APR-03 . In the main text of the document. however. health and family planning. are given in the Reproductive Health Profile. PAGE 5 O F 95 . The source of information is also cited. different figures would be found. at places.

................16 POPULATION AND DEVELOPMENT POLICIES: CHALLENGES AND REALITIES.............. 30 G..13 I...................................................................................................................................... 36 Maternal Morbidity: ......27 Infant and Child Mortality...........................................31 1.......22 SPATIAL DISTRIBUTION OF THE POPULATION.........................................13 THE M ACRO-ECONOMIC SITUATION .. E..........17 LITERACY AND EDUCATION........................................ H.....................................36 REPRODUCTIVE HEALTH AND FAMILY PLANNING................................................ 40 PAGE 6 O F 95 ... F.......................... Fertility Differentials ..................................36 M ATERNAL AND INFANT MORTALITY.......................... K.................................................................. C..................................................... CHAPTER THREE ......................................................................................................... TRENDS AND CHARACTERISTICS............................... 5.................................................................................................................. II.............................. Reproductive health in Pakistan..................................22 POPULATION LEVELS..................... Maternal Mortality:........................... 31 2....16 HUMAN RESOURCE DEVELOPMENT .14-APR-03 ....................... FERTILITY ...................................................................................................................................... 2...............20 POPULATION AND ENVIRONMENTAL ISSUES............. ............................................................................ A......................................................................36 I..............................................22 Human Development................................. D........................ 30 2.............................13 DEMOGRAPHIC AND SOCIAL CHANGE ............26 M ORTALITY ......................................... I................................................................................................ D... Demographic and Reproductive Health Indicators ....14 INTER-SECTORAL LINKAGES ....................TABLE OF CONTENTS C HAPTER 1 ........... E.............. J.......................................................... Overview................................................. B.................................... 39 Evidence-based Decision-making in Safe Motherhood Programming:................................................ M IGRATION .......................................... 28 F....................................................................21 CHAPTER 2......................13 POPULATION AND DEVELOPMENT.................................................... 3............30 1...........23 AGE-SEX COMPOSITION OF THE POPULATION ............................................ Sustainable Development and Poverty...19 GENDER EQUALITY AND EMPOWERMENT OF WOMEN:......................................................................................... Internal Migration ............................ 4.............................................. Relationship between Population.......................................17 HEALTH AND REPRODUCTIVE HEALTH STATUS.............................................................................24 PROJECTED POPULATION.............................................. G......... 38 Infant Mortality:.................................................. A.. A...................22 POPULATION GROWTH........................................................................................................... B........................................................................36 1. 34 1.............................................................. 32 3......... Urbanization and Growth of Cities.....................................................................................................................................................22 I................................................................................................. Trends in Fertility...................................................................13 ICPD CONTEXT ................................................... International Migration........................... C......... 39 Major Issues in Safe Motherhood:...............18 LABOUR FORCE AND EMPLOYMENT..................................................................................................................................................................

................................................................................................................................... THE POTENTIAL ROLE OF CIVIL SOCIETY ....................................................... 65 a) Regulatory issues ....................50 Policy framework......... Community participation.. Organized Public and private sector ......................................................................................................................................................................................................................... Issues............................ 2...............................................................67 AN UNDERUTILIZED PUBLIC SECTORS......... 64 5................................................................................................... Private health care........ 63 2........................................................................................................................................... Abortion:...... 50 Population policy framework .....................................65 c) Affordability ......... 46 2................................................................................................................................... 64 4......41 Contraceptive prevalence ............................................................ 63 3.......................................................................... 71 2..................................14-APR-03 ....................................44 1.............................................. 56 4................................................... 69 D........................................................................................................58 c) Human Resource Development ................................... OTHERS...................... The offer of services.... 57 a) Harmonization of RH services................ Ministry of Health ........ A........................................................................... 47 E......................................................66 a) b) III......................................................................................................................... Infertility:..........................67 LACK OF AWARENESS WITHIN THE COMMUNITY ............................................................................................................... A DETERMINANT GROUP : ADOLESCENTS.....................................................................66 d) Support to NGO sector ............................................................... B............71 1.... FAMILY PLANNING...............48 1........... 72 a) Political Leadership:........ Social Marketing Organizations..67 SOCIAL AND CULTURAL FACTORS....57 b) Devolution and Reproductive Health Services....... C.....................................................................................................................53 2.......................................63 1.... Issues....................60 e) Logistics and availability of contraceptives ...... II........62 B....................... 42 Unmet need of family planning:................................................... NGO/For non profit.................................................................................... 68 Male involvement................................................59 d) Quality of services...........B...................................................................................................................................61 f) Health Management Information Systems (HMIS) ..................................... 44 D...................... PAGE 7 O F 95 .............................................................................................50 Health policy framework......................................... Ministry of Population Welfare.. An insufficient demand for services................................................................................................................................................................................72 b) Devolution and its Implications on District Health Services .......................................................................73 1............... 43 C................... 2... SEXUALLY TRANSMITTED INFECTIONS AND HIV/ AIDS .............................. 1.............................................................................. 54 3........ Cancers of Reproductive Tract.......................................................................................................................... 46 3.............................................................................................................. A......... Devolution and local political environment........................................................................................................50 PUBLIC SECTOR...................................................................................................................................................... PRIVATE SECTOR ..........46 1.......................65 b) Linkages with public sector...........................................68 Gender....................... Response TO HIV/AIDS and STIs............................................................................................

.............. Achievements.................................................................90 1................................................................................................................................................. The Financial Resource Gap of Pakistan’s Population Welfare Programme ........................................... Expenditure on Pakistan’s Population Planning Programme in pre.....84 CHAPTER 5:........................ 86 Recommendations....14-APR-03 ..87 SERVING BETTER AND REACHING OUT ............................................................................................................................. NGOs’ and Private Sector’s Role in Financing of Population and Reproductive Health Activities ................................................................................... and a Comparison With Countries in the South Asia Region........... Resource allocations and expenditure of the Population and Reproductive Health Programme and their relationship with the policy recommendations .........................................................................................................................74 III....................CHAPTER 4..................... 2... 88 B.................................................... NATIONAL ADVOCACY AND COMMUNICATION STRATEGY................................................................... REPRODUCTIVE HEALTH AND GENDER.........90 BUILDING ALLIANCES AND SUPPORTING COMMUNIT IES......81 VIII.......... A.............................................. Serving and managing better – the path to improved service delivery..................................................................................... 1................................................. 87 Recommendations................................... Public Sector’s Planning................................................................................87 Achievements............................................................................................ Overview.................... The Role of External Assistance in Financing the Population and Reproductive Health Programme....................74 MOBILIZATION OF FINANCIAL RESOURCES FOR POPULATION AND REPRODUCTIVE HEALTH PROGRAMMES....................................75 IV................. A review of social sector expenditures in Pakistan and assessment of reasons for these being historically low .......................................................................................... II................................. Budgeting and Financing Structure and its Rela tionship with the Population Programme.......................................... SAVING MOTHERS...........................79 VI............................................. Achievements..............74 II...........................................................85 I.74 I.................................................................................................................................................................................... 2.. Family health for human wealth......................................................................... 90 PAGE 8 O F 95 ......................................................................... A...................81 VII............................................. Recommendations................................................ Devolution of Authority........ 89 IV............................................................................................... Recommendations. 1.................................................................................... 86 B.....................................................................................86 Achievements................ 86 2........85 Child spacing – A national cause .85 RECOMMENDATIONS FOR STRATEGIC ACTIONS IN POPULATION...........................76 V...............................................86 1........... 89 2.................. A.............. Achievements.....................................82 IX.................... 87 III.............................................89 1......85 ADJUSTING EXISTING POLICIES ........................................................................and post-ICPD period.......................................................................................... Introduction .....................

........................... POPULATION AND RH M ONITORING .......93 1..........................14-APR-03 ................................................................................. A................................2.............................................................................. Achievements............................. PAGE 9 O F 95 .. Achievements..... Recommendations......................................... 93 Recommendations........................................ 92 2............................. 2..... 94 1......... Recommendations...................................................................... 93 B................................................................................. Recommendations..92 1...................................93 DEVOLUTION .......................................................91 Achievements.... 90 Knowing better.......................................... V.................................................93 Achievements.................... 2........................................................................... AN IMPORTANT STEP ................ 91 Recommendations........................... A......... ENHANCING DISTRICT MANAGEMENT CAPACITY.....................91 ENHANCING NATIONAL EXPERTISE ............... 1............. 91 B............................................................................................................ Managing better – towards a reliable supply and optimal use of resources.......... 92 VI.......................................................................................................................................... 93 2.............................................................................................................................................................

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 PAGE 10 O F 95 .14-APR-03 .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.

14-APR-03 .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 Minister’s 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 World’s 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 PAGE 11 O F 95 .

too numerous to mention. We gratefully acknowledge the contribution by all the aforementioned individuals. Ministry of Health. Rehana Ahmad of SMP. Mr. and also those from the federal ministries. Individual chapters were assigned to Dr. Shahina Manzoor of Fatima Jinnah Medical College and Mr. Dr.14-APR-03 .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. Dr. NGOs and other stake-holders. Zeba Sathar acted as the Report Advisor. provincial departments. Economic Affairs Division and UNFPA. Naushin Mahmud of PIDE. Mehtab Karim of Aga Khan University. Farid Midhat of Population Council. Dr. NGOs and others. Farida Ali provided secretarial assistance. Dr. Mehboob Sultan of NIPS. PAGE 12 O F 95 . a working group was set up with representatives from the Ministry of Population Welfare. Masood Hayat of Dataline. To oversee the preparation. Ms. Dr. who invested their considerable time in reviewing the document and providing their comments.

8 births by 2000-01.Chapter 1 POPULATION AND DEVELOPMENT I. (Source: Population Census Organization. the urban population has registered higher growth rates of 3. social and macro-economic situation in the ICPD context.16 in 2001.5 percent. housing. and reproductive health. DEMOGRAPHIC AND SOCIAL CHANGE Pakistan’s population increased from about 34 million in 1951 to nearly 132 million according to the 1998 census. which now requires much larger resources to create more employment opportunities for this section of the population. About 50 percent PAGE 13 O F 95 . therefore. The total fertility rate (TFR) has also exhibited a modest decline from more than five births per woman in the early 1990s to 4. 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. ICPD CONTEXT Moreover. 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.69 percent during the inter-censal period of 1981-1998 to 2. the population welfare programme frequently underwent structural. 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. Pakistan has shown some progress in the field of population and development. 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. A consequence of high fertility rates is the unusually high number of young and adolescent population. A .14-APR-03 . B . It was estimated as 146 million in mid-2002. health. administrative and policy changes within a fluctuating political environment. However. It is. The investments made in social sectors. RELATIONSHIP BETWEEN POPULATION. water and sanitation and infrastructure have not kept pace with the rapidly growing population. 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. Since Pakistan is a signatory to the 1994 ICPD Programme of Action. adversely affecting its commitment for realizing its objectives. The population growth rate has declined from an average annual estimate of 2. s uch as education. After the 1994 ICPD. with 33 percent of the population living in urban areas. in particular. 1998 Census Report of Pakistan and Economic Survey 2001-02) and is expected to reach 220 million by the year 2020. leading to a continually growing labour force. with an increasing demand for basic civil and social amenities. The subsequent section assesses the progress Pakistan has made in terms of demographic. In the post-ICPD period. Reproductive Health and Family Planning Survey 2001-02).

Although Pakistan appears to have made a breakthrough in achieving a declining trend in fertility and population growth rate.M.5 million in 2002. PIDE). and high infant mortality rate.6 million in 1995 to 41. Furthermore. Pakistan’s reasonably high growth rate of 6 percent as its Gross National Product (GNP) declined to 4 percent. edible oil. mainly due to tight monetary -4 policy. chemicals. increasing from about 35 percent in 1990-91 to around 45 percent in 1998 for the total population. which in turn affected investment adversely and impeded economic growth. more than 3 million persons are unemployed. still leaving about 70 percent as illiterate (Source: Population Census Organization. C . while the share of manufactured and industrial goods increased from 57 percent to 72 percent during the same period. The poverty level has increased from 27 percent in 1993-94 to about 35 percent in 1999-2000. fiscal management and improved supply of food items in the country. the country experienced sustained inflation ranging between 10 to 13 percent during the 1990s. during the years 1999-2001. diminished to around 3 percent in recent years. the annual growth rate of exports stagnated at 13. Government of Pakistan). e The trade deficit and the balance of tc. Changes in other major indicators relevant to population and development show that literacy rate has progressed at a very slow pace. the value of human development index (HDI) in Pakistan is low (0. are additional sources of concern for the country’s population and development programmes. 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. If under-employment is also taken into account. it changed from only 20 percent to 30 percent during the same period. ranking it as 135th country of the world. making it the sixth most populous country of the world and the third in the Asian region. The total labour force in the country has increased from 33. the share of exports of primary commodities in the agricultural sector has declined from 19 percent to 13 percent. This indicates that more than one-third of the total households in Pakistan are living below the poverty line. and possibly even lower to 3 percent. 1998 Census Report of Pakistan). and of semi-manufactured goods from 24 percent to 15 percent. indicating an unemployment rate of about 8 percent. With low levels of adult literacy. 9th Five Year Plan 1998-2003. During 1990-91. The per capita income was estimated at US $495 in year 2000-01 (Source: Planning Commission 1998.. PAGE 14 O F 95 . The composition of imports. The persistence of large fiscal and current account deficits during the 1990s were the main underlying cause of macroeconomic instability. these changes are modest and below the desired level. fertilizer. and this level is very close to 40 percent in rural areas (Source: Arif G. The inflationary pressures have. For females. however.522). inadequate coverage and access to primary health care and reproductive health services. THE MACRO-ECONOMIC S ITUATION In the decade of the Nineties. on the other hand. has not witnessed any appreciable change. However. Of these.6 percent of GDP. petroleum products. as a result of Pakistan’s efforts to improve its macro-economic stability through the consolidation of its economic policies and human resource development.of the total population lives in one-room houses with inadequate access to sanitation and sewerage facilities. during the 1990s. 2001. Measuring Poverty in Pakistan: A Critical Review of Recent Poverty Line. tea. Consequently. The population growth in Pakistan is still among the highest in Asia. largely concentrating in capital goods machinery. showing mixed results. along with a large fiscal deficit of around 7 percent of GDP. the unemployment rate rises to around 15 percent.14-APR-03 . or around the value of US $ 8 billion.

The evaluation of these programmes point out their limited success in realizing the intended objectives. 2002). initiated in 2000-01. female-headed households.557 million per annum. incorporates a comprehensive economic revival programme aimed at accelerating economic growth and social development (Source: Interim Poverty Reduction Strategy Paper.2 14.9 to 3. Estimates reveal that in rural areas.8 20. lesser or no education.36. the market friendly policies including deregulation and privatization of public enterprises were adopted to promote investment.5 30. with an average estimate of 4. (Source: Amjad and A. from 19. the economic growth rates have not been adequate enough to benefit the poor. as well as resulting in rising levels of unemployment.payment position of the country during the 1990s has remained under pressure.0 33. The Poverty Reduction Strategy of Pakistan (PRSP). The core principles and objectives of this strategy PAGE 15 O F 95 . 2001).5 billion in 1990-91 to $36.1). Official Poverty Line) * Estimates for 1998-2000 are based on 2250 calories per adult for rural areas. growth and productivity.3% during the same period (Source: Economic Survey. Debt servicing as percentage of GDP has increased from 2. unskilled labourers. 2001. and 2295 calories per adult for urban areas (Qureshi and Arif.7 percent during the same period (Table 1. Macro-economic Policies and their Impact on Poverty Alleviation in Pakistan.9 27.8 15. estimates are based on 2350 calories per adult at national level. 1997. The Pakistan Development Review.7 39. Government of Pakistan). the Structural Adjustment Programmes that were pursued also affected various segments of population disproportionately. and the aged in poor families. Islamabad).14-APR-03 .9 percent in poor households. In this regard.8 percent during the years 1992-1993 to 1999-2000.8 percent to 31.0 28. and in urban areas. Vol.5 billion by end-2002.7 34.2 Urban 19. Government of Pakistan. especially among the youth.Kemal.7 24. 1998-99. Studies have also shown that poor households are higher in number in rural than in urban areas. and devote a large proportion of their consumption expenditure on food as compared to those in non-poor households. The poor households are generally characterized by larger family size.8 Source: Arif (2001) Notes: Poverty estimates are based on basic needs approach. However. * From 1993-99.6 35. Despite the efforts made to reduce poverty during the past decade.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. No.1.0 percent to 39. 2450 calories for rural areas and 2150 calories for urban areas (Planning Commission. (Source: Government of Pakistan 2002). Table 1. the proportion of poor households has increased from 27. The external debt burden increased from $15.5 percent of GDP or US $ 2.R.9 31.7 Rural 27. accentuating both poverty and related socio-economic problems in the country. The percentage of literate household heads in non-poor households is 52 percent as compared with 27. The evidence shows that poverty-afflicted groups are generally the landless and small farmers. the u nemployed. 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.

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. including NGOs and the private sector. Therefore. employment and training. These sectors include education. Working PAGE 16 O F 95 . 2002). Hence. Under the new population policy.14-APR-03 . progress in literacy and education has been much below the desired levels.are: reforming macro-economic imbalances. iii) promoting gender equality and empowering women. The new population policy 2002 plans to bring down population growth rate from its current level to 1. women in development. improving access to income generating activities and employment opportunities. E. has declared eight Millennium Development Goals (MDGs) which fit seamlessly into the 1994 ICPD Programme of Action. 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. Consequently. vii) ensuring environmental sustainability. the programmes include service delivery. v) improving maternal health. etc. POPULATION AND DEVELOPMENT POLICIES: CHA LLENGES AND REALITIES Pakistan’s development strategy in the past was growth-oriented. and reducing vulnerability to shocks through social safety net schemes at the national and provincial levels. Given the urgency and critical situation of the population issues in terms of its high momentum of growth and a fast. The United Nations Millennium Summit of 2001 to which Pakistan is a signatory. To achieve this end. information and the media. and viii) developing a global partnership for development. 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. malaria and other diseases. 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. advocacy and operational research in population and development. the foundations for a multi-sectoral approach have been laid down to ensure integration of population into overall and sectoral planning. 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. vi) combating HIV/AIDS. A number of programmes framed under this strategy are expected to serve a substantial number of the poor and the youth in the country.9 percent by the year 2004 and 1. training and capacity building. physical planning and housing. INTER-SECTORAL LINKAGES Population is recognized as a major cross-cutting issue in all development plans of Pakistan.growing dependent and youth population. 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. based on the premise that the effects of economic growth would filter down to the masses. 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. iv) reducing child mortality.3 percent by 2020. health. the Five Year Plan involves all sectors in exploring ways in which population problems and their consequences can be comprehensively addressed. and provide guidelines for the operationalization of population and development policy of Pakistan. These goals are: i) eradicating extreme poverty and hunger. D. ii) achieving universal primary education. improving social sector development and outcomes.

’98 The statistical evidence based on the 1998 census results shows that of the total formal literate population.129.1 30. the net enrolment rate.751 Males Literacy Rate (%) 25. a major challenge for Pakistan’s development agenda is to achieve rapid economic growth. and reduce its fertility and population growth rate to maximize its gains for population welfare.856 89.077. In this context. which accounts for the over-age children enrolled at primary level. Table 1.0 32. especially for girls at primary and secondary levels.941 23.998 19.910 56.800 Literacy Rate (%) 16.966 42. and for females from as low as 8 to 32 during the same period (Table 1. being 47 percent for boys and 37 percent for girls. Literacy rates in Pakistan have increased gradually over the past decades from 18.9 Population (10+) 14.8 Females Population (10+) 121.4 percent in 1961 to about 44 percent according to the 1998 population census results.916.411.565. Of these.2: Census Year 1961 1972 1981 1998 Trends in Literacy Rates (population 10 and above) by Sex: Pakistan 1981-1998 Both Sexes Population (10+) 26.953. and has PAGE 17 O F 95 .0 Source: Population Census Organization. The ratio of female to male enrolment has improved at all levels of education during the past two decades. ‘72.842.7 21. occupational structure of the labour force. This indicates that about 50 million of the total population.7 26.890 46.049 Literacy Rate (%) 6.939 42. Population Censuses of Pakistan. School enrolment has also increased considerably. ‘81.100.1 54.460 30. enhance investment in its basic social sectors. 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.351. HUMAN RESOURCE DEVELOPMENT G. 18 percent have attained below primary and 51 percent have completed primary and middle levels. LITERACY AND EDUCATION Attainment of education is one of the major components of human resource development which affects economic growth. around 21 million males and 29 million females (10 years and above) are counted as illiterates in Pakistan. F. The corresponding gross enrolment ratio (GER) at primary level is estimated at 71-80 percent for boys and 61 percent for girls.6 16.14-APR-03 . more than 90 percent have attained education up to matric and intermediate levels. and to the benefit of the poor. This percentage increased from 27 to 55 for males.260. personal income and demographic behaviour of population. to produce a well-trained and educated workforce.2 43.7 11. including better reproductive health. is reduced down to 42 percent for total primary school age population (5-9 years). especially education. However.2).450 26. 1961.889. adoption of new technologies. universal education and gender equality.2 35.338. Although the female literacy level has almost doubled between 1981 and 1998. Enrolment of primary level increased from 10 million in 1990-91 to 18 million in 1998-99.towards these goals would reinforce the important goals adopted by the ICPD.

improving primary and secondary health care services. a National Health Policy of 2001 with the motto of ‘Health for All’ was framed. Islamabad). are likely to improve the access to health care services and raise the health status of population (Ministry of Health.7 23.5 College/Tertiary 35. Pakistan on an average has allocated 2.000 women die each year due to pregnancy-related complications and maternal mortality remains between 300-700 per 100. private medical sector.8 49.0 58. correcting urban b regulating ias. To meet the challenges of the health sector. aimed at reforming ten major areas in the health sector to reduce mortality.7 52. The contraceptive prevalence rate is around 28 percent (2000-2001) – one of the lowest in the region. morbidity and malnutrition. About 33 percent of married women do not want to have more births after three children.5% of GNP to education during the development plan periods. National Institute of Population Studies. creating mass awareness about health and reproductive health matters. Nearly 80 percent of deliveries take place at home. improving nutritional deficiencies.5 University 28.3: 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. females constitute more than 60 percent of male enrolments.5 Secondary 25. especially among infants and mothers.3).5 35. Some basic facts about the country’s reproductive health situation indicate that more than 20.6 Source: Federal Bureau of Statistics: 1998. These reforms.4 21.9 71. the allocated share (48%) remains insufficient in achieving the target of universal primary education by the end of the 9th Plan (Source: Planning Commission 1998.2 40.9 68. 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. H. However.000 live births. The recent improvement in school participation is attributable to increased investments in public primary schools which targeted at least one school per village. These include reducing prevalence of communicable diseases. 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.contributed towards the lessening of gender inequities in education in recent years. if implemented. 9th Five Year Plan 1998-2003. which is below the UNESCO recommendation of at least 4%. Government of Pakistan.9 31. 2002). especially in towns and cities.8 49. Table 1. PAGE 18 O F 95 .4 64.7 32. yet do not protect themselves against unwanted pregnancies. sex ratio of enrolment is 58 percent and 31 percent respectively for the year 2000-01 (Table 1. 2002). while at secondary and university levels.1 37. middle and college level of education. At primary.2 Middle 25.7 51. most often attended by untrained personnel (Source: Reproductive Health & Family Planning Survey. manpower capacity building.14-APR-03 . and the opening up of significant number of private schools.

and large amounts are spent on non-development/recurring expenditures to support the large infrastructure and salaries of the staff (Table 1.688 Recurring Budget 10.08 24.7 percent to health during the previous development plans.7 Source: Pakistan Economic Survey.7 0.4).35 18. the development budget on health is only a small fraction of the total.857 13. Moreover. if deflated by GDP growth and inflation rate.44 11. transport and other sectors (Economic Survey. Pakistan Institute of Development Economics. 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 16.34 19.Pakistan. LABOUR FORCE AND EMPLOYMENT Given the high fertility experience during the past decades.741 6. the current rate of growth of Pakistan’s labour force is over 2 percent per annum.944 6. 5: Unemployment Rates Among the Youth Population: 1993-94 to 1999-2000 PAGE 19 O F 95 . Table 1. followed by the services (15%).587 15. trade (14%) and manufacturing (11%) sector.492 5. on an average.316 16. about 41 million are in the labour force. with a crude economic activity rate of about 29 percent.14-APR-03 . the real expenditure on health does not show a significant increase over the years (Macro-economics of Pakistan’s Economy.7 0.190 18.077 5. 2001-2002 I.28 25.81 22.485 6. and a refined activity rate of 43 percent for all Pakistan. However. 2000). has allocated 0. Of the estimated population of 143 million in the year 2001.05 (million Rs) Development 5.7 0. 2000-01).66 20.8 0. Table 1.7 0.337 18. and the remaining are employed in construction.887 5. The majority of the labour force is employed in agriculture and related work (48%).717 % of GDP 0.8 0.

but in an uneven and a disproportionate way. Both as children and growing adults. 15 billion allocated for the year 2002-2003.6 5.1 Rural 7.0 6.4 10.2 Rural 13. However.3 Source: Labour Force Surveys: 1993-94 and 1999-2000 To deal with the severity of the problem. 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. child mortality. and additional Rs. implying that there is a better health coverage of the female population and a resultant change in their mortality rate. The Khushal Pakistan Programme. it has been generally observed that gender discrimination prevails at all stages of life cycle.7 3. This has created one million temporary jobs in the rural areas and small towns with an expenditure of Rs.7 8. 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. females have a greater incidence of malnutrition. the age structure of both women and men is heavily weighted towards younger and unproductive ages. The small and medium enterprises (SMEs) programme launched in 2002 aims to provide small loans to the poor.7 Total 15. 2000). About 43 percent of population is below 15 years of age.Age Group Total 15-19 20-24 25-29 9.6 6.5 5.4 9. vocational and apprenticeship programmes for both men and women. Recent changes in the socio-demographic dimensions suggest that women have not only contributed but have gained from the development process.2 11. The gender gaps in literacy are more evident in rural than urban areas.1 14. While in recent years women have considerably benefited from increased education facilities.489 and a gender empowerment measure (GEM) with a value of 0. the Government of P akistan has launched many employment promotion programmes in recent years. and has created about one thousand jobs. Pakistan fully recognizes the need for the enhancement of women’s participation in national development and their full integration into all development programmes. Some progress has been achieved in developing women’s capabilities and productive activities. Pakistan ranks low in terms of gender development index (GDI) with a value of 0. The literacy rate for females is almost half of that of males. PAGE 20 O F 95 . was launched in 2001 to improve poor people’s access to credit for their self-employment. J.179 (UNDP. vast gender disparities still exist in literacy and school enrolment rates. As a result of the continuing high rate of population growth. in accordance with the labour market needs and demands of the growing labour force. Currently.2 1999-2000 Urban 19. Further initiatives have also been undertaken to involve the private sector in expanding technical. Recent census and survey or estimates indicate an improvement in sex ratio and female life expectancy at birth.4 1993-94 Urban 13. 21 percent in the case of females and 22 percent f males. and lesser opportunities in access to education and employment than males.7 2. 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. 24 billion.14-APR-03 . With the beginning of fertility transition in recent years.0 5.

2000). Naushin. K . 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. If measured in terms of carbon dioxide emissions. There are few options for paid jobs in rural areas and most women work as unpaid family helpers on farms and agricultural activities. their productive work for the household and the economy remains invisible and undervalued.9 percent per annum as compared with 0.3 million metric tonnes in 1996 (Source: Human Development Report. Such a situation has resulted in a massive soil and land degradation affecting agriculture. Low levels of education among women. POPULATION AND ENVIRONMENTAL ISSUES. the annual rate of deforestation was 2. The Ministry of Women Development has initiated various programs to improve women’s situation and has identified 12 critical areas for mainstreaming gender into developmental activities.7 percent for low income countries. limited employment opportunities and cultural constraints in working outside the home combine to limit women’s employment in the formal sector. Estimates show that during 1990-95. lack of implementation of the quality standards for industrial pollution and the lack of defined property rights are contributing to environmental degradation in Pakistan. Moreover. 2002. consumption patterns and life style. Water-logging and salinity and the extensive use of extremely toxic pesticides in agriculture adversely affect land productivity and health of the people. therefore. This is damaging the ozone layer and entire ecological cycles affecting animal and plant life. 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. air pollution has increased markedly as a result of vehicular emissions and industrial pollution. It is encouraging to note that the achievement of gender equity is recognized as a cross cutting theme for all development programs in Pakistan. necessary to plan the growth of cities in a scientific manner. 1997). of which 30 percent is economically utilized (SDPI.as only 20 percent of rural females were literate compared with 48 percent of rural males as reported in the 1998 census. the changing socio-economic conditions have resulted in increased participation of women in the wage sector.6 million metric tonnes in 1980 to 94. However. PAGE 21 O F 95 . Besides the adverse effects of unplanned urban growth.14-APR-03 . especially in urban areas and in informal employment. Gender Issues and Socio-economic Development. and the number of illiterate women (29 million) are about 60 percent of total illiterates in the country (Source: Mahmood. 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. Population pressures have also resulted in the over-use of land resources and acute water shortages. particularly in the industrialized world. 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. crop cultivation. Only 5 percent of the total land area is under forest. and other economic activities on which human survival itself depends. Pakistan is also confronted with the problem of deforestation. Increased urbanization is likely to change occupational structures. fishery and livestock productivity. Hence. Besides overcrowding. it has increased from 31. Country Report of Pakistan. It is.

Pakistan’s per capita GNP was higher than several of its immediate Asian neighbours. namely. Table 2. over time. the population growth rate averaged 1.7 per cent during the 1981-98 inter-censal period. Of special concern is the slow pace of improvement in these indicators in the country in the recent past. fertility.1. the annual rate of population growth in the country had peaked at 3. Pakistan has made slow progress in reducing its total fertility rate. NIPS. suggests that until the early 1990s. OVERVIEW The demographic scene in Pakistan has two distinct features. In this chapter the changes and differentials that have occurred are examined under three demographic parameters. reaching 2. Pakistan was lagging behind in most human development. showing the crude birth and death rates derived from Pakistan Demographic Surveys.16% per annum. while during the second half.2. it showed a gradual decline to 3. DEMOGRAPHIC AND REPRODUCTIVE HEALTH INDICATORS Even though at the end of the 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. demographic and reproductive health indicators. However.1 percent during the 197281 inter-censal period and to 2. By the time of the 1972 Census. HUMAN DEVELOPMENT. it has one of the highest population growth rate in South Asia: in mid-2002 it was estimated to be 2. This has brought about significant demographic changes. PAGE 22 O F 95 . between the first post-independence Census of 1951 and the last census conducted in 1998. Secondly. 1 The State of Population in Pakistan. A . mortality and migration. TRENDS AND CHARACTERISTICS I. adding about a 100 million people.Chapter 2 POPULATION LEVELS. Similarly. migration has had a pronounced effect: there has been substantial in-country migration. Firstly.01 percent per annum. in the areas now constituting Pakistan. Urban population growth has accelerated and there has been a shift in the share of the provinces in the total population. As shown in Table 2. the population of the country increased four times. the growth rate averaged about 3 percent per annum.14-APR-03 . as compared to other countries in the region. II.2 percent at the end of the decade. 1987. large scale influx of war-driven Afghan refugees and entry of other illegal migrants seeking domestic employment.6 per cent during the 1961-72 inter-census periods. POPULATION GROWTH During the first half of the 20th century.

The provincial percentage share in the total population of the country has been changing. has only five percent of the country’s population and has a density of 19 persons per square kilometer. Balochistan.321 84. Thus.2 3. 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).TABLE 2. B . SPATIAL DISTRIBUTION OF THE POPULATION As shown in Table 2.6 2.0 2. This has partly been due to inter-provincial migration and different fertility rates. While the share of NWFP has remained somewhat similar (about 13.45 3.06 2. that of Balochistan increased from 3.80 2.2 Source: Federal Bureau of Statistics.67 3.3. PAGE 23 O F 95 .2: CRUDE BIRTH. 1: 1951 1961 1972 1981 1998 POPULATION GROWTH RATE IN PAKISTAN: 1951-2002 Population (000) 33. Punjab on the other hand.978 65. with only one-fourth of total land area of the country.69 TABLE 2. the share of Sindh has increased from 18 percent to 23 percent.352 Sources: Population Censuses of Pakistan. Thus. is the most densely populated province.817 42. during the same period. it contains over 55 percent of population. On the other hand.5 percent in 1951 to 5 percent in 1998. which contains about 44 percent of the land mass. Census Year Percent Annual Growth Rate during the Inter-censal period 1. 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. 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. Pakistan’s population is quite unevenly distributed among the four provinces.14-APR-03 .254 132. the share of Punjab declined from 61 percent in 1951 to 57 percent in 1998. Pakistan Demographic Surveys.5 percent).

587 62 13.158 101 21. that during the recent past Pakistan’s birth rate has declined.0 73.3 8. the overall age structure of the population is heavily weighted towards PAGE 24 O F 95 .M.220 Sq K. 1961- Population (in 000) 1951 Pakistan (Area 796.8 235 259 0.6 33.137 49 4.3 120 132 0.253 106 100. due to the persistently high birth rate in the recent past.6 14.752 77 13.744 238 13.5 1.M. However.M.190 Sq K.6 11.332 13 5.521 Sq K.7 8.3 C .8 2.4 6.3.) Density per square Percent of Pakistan’s total population Punjab (Area 205.6 30.557 100 60.0 37.) Density per square Percent of Pakistan’s total population Balochistan (Area 347.1 19.0 20.6 1.321 82 100.M.4 805 889 0.M.) Density per square Percent of Pakistan’s total population Islamabad (Area 906 Sq K.M.) Density per square Percent of Pakistan’s total population Source: Population Censuses of Pakistan 1961 42.7 2. it also reveals a smaller proportion of population in the youngest age group.392 113 12.029 135 22.054 43 17.187 3 3.8 6.978 54 100.433 7 3.0 47.0 3.440 216 23.847 68 4.566 19 5.) Density per square Percent of Pakistan’s total population NWFP (Area 74.0 17.914 Sq K.4 1981 84.385 4 3.M. However.199 81 2.14-APR-03 .176 117 2.3: 1998 POPULATION DISTRIBUTION AND DENSITY BY PROVINCES.352 166 100.374 59 19. shows a typical pattern of higher percentage in the younger age groups.4 and in Figure 1.6 340 375 0.) Density per square Percent of Pakistan’s total population Sindh (Area 140.344 Sq K.491 92 3.612 183 57. AGE-SEX COMPOSITION OF THE POPULATION Age-sex composition of the population.1 2.292 230 56.4 1.816 43 100.) Density per square Percent of Pakistan’s total population FATA (Area 27.4 1998 132.9 4.0 094 104 0.TABLE 2.621 358 55.2 1.3 1972 65. presented in Table 2.061 148 13.5 5. confirming the findings reported in Table 2.0 25.500 124 59.1 4.095 Sq K.

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.

PAGE 25 O F 95 - 14-APR-03

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 country’s 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.

PAGE 26 O F 95 - 14-APR-03

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.

2

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

PAGE 27 O F 95 - 14-APR-03

6 15. In the most recent period (1997-2000). the mortality rates for males are higher during the neonatal.9 Source: Federal Bureau of Statistics.7 1.5 7.4 45.3 8. 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 7.7 3.1 3. infant.8 46.14-APR-03 .2 4.TABLE 2. an interesting pattern of sex differential in early childhood mortality is reported.2 1.7 5.4 2.0 3.1 19. although it remained somewhat stagnant during much of the 1980s and was reported as 82 per 1000 live births during 1997-2000.4 3.9 16. For example.6: AGE & SEX SPECIFIC DEATH RATES (PER 1000). one done in 1996-97 and the second in 2000-01.0 1.3 8. child mortality declined from 25 to 20 per thousand live births and under-five mortality has declined from 136 to 103.7 3.4 1.5 8.4 5. post-neonatal. The proportion of neonatal deaths is higher compared to post-natal deaths.7 18.7 2.0 1.0 3.6 9.9 2.3 7.7 1.8 1. child and under five mortality.2 1.9 Male 8.3 10.6 1. these differential rates are useful for evaluating the country’s health policies and programmes.3 2.6 1.4 1. These findings suggest that the risk of death during early childhood is the highest during the first four weeks following birth.4 100. Pakistan Demographic Survey-2000 1.1 1. post-neonatal period as PAGE 28 O F 95 .6 2. During the period 1982-86 to 1997-2000.5 44.0 11. 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).8 111.2 122.6 Female 7.3 3. When further disaggregated into different categories of neonatal. compared with the remaining 48 weeks of the first year. PAKISTAN. 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. indicating a need to focus both on pregnant women as well as neonates in the child survival strategy.

thereafter the child mortality rate is substantially higher for females. presented in Table 2.7: Sex and Period EARLY AND LATE CHILDHOOD MORTALITY RATES BY SEX. Under-five Mortality: probability of dying before the fifth birthday. However. Differentials in IMR.8. 2000-01 Neonatal Mortality: probability of dying within the first month of life. particularly among mothers with middle or higher levels of education. TABLE 2. TABLE 2. could be reflective of the relative absence of quality maternal child health care services and facilities in the province. Pakistan Reproductive Health and Family Planning Survey. Post-neonatal Mortality: probability of dying between the first month of life and exact age one year. suggesting that less attention is given to the overall health of girls and. as expected. therefore. The IMR is reported to be lower in the major urban areas. having survived the first month. Child Mortality: probability of dying between the first and fifth birthday. and when they received both antenatal and post natal care during the period of pregnancy and subsequent childbirth.14-APR-03 .well as during infancy. 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. they are at a higher risk of dying than the male children.8: DIFFERENTIALS IN INFANT MORTALITY RATES BY BACKGROUND CHARACTERISTICS: 1992-96 PAGE 29 O F 95 . Infant Mortality: probability of dying before the first birthday. having survived the first year.

2 6.0 1986-91 4. whereas in the rural areas the decline has been quite modest (from 6. 1984-2000 Area Major Urban Other Urban Rural Total 1984-85 5.4 1992-96 3.9 5.4 4. Pakistan Reproductive Health and Family Planning Survey.4). During this period. the TFR declined from 5. TABLE 2.14-APR-03 .2 5. FERTILITY 1.4 1997-2000 3.5 6.9: TRENDS IN TOTAL FERTILITY RATE.9). which are more developed economically as compared to the two less developed provinces of PAGE 30 O F 95 .1 to 4. Since then a gradual decline in TFR has led to 4. a slightly lower fertility is reported in the two provinces of Punjab and Sindh.4 in the major urban areas and from 6. 2000-1 2.4 4. TRENDS IN FERTILITY The fertility rates in Pakistan remained high until the 1980s. Foremost among them is the higher level of female education and higher age at marriage among urban women.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. whereas in much of the rural area such services remain scarce.0 in other urban areas.10. 1996-97 F.9 4. The most notable change in the TFR has occurred in the urban areas of the country.8 Source: National Institute of Population Studies.8 5. which was reported at the end of the decade (Table 2. FERTILITY DIFFERENTIALS As shown in Table 2. Also urban areas have been provided regular family planning services by the government.1 6. it is notable that the gap between the rural and the urban areas has widened substantially.7 5. During the 1985-2000 period. There are several reasons for this rapid decline in urban fertility.6 5. NGOs and the private sector (social marketing and commercial sales). Pakistan Fertility and Family Planning Survey.8 births per woman.0 5.5 to 3. when the total fertility rate (TFR) was about 6 births per woman.2 to 5.

This suggests that in Punjab rural-to-rural migration is more prevalent. Less than 30 percent settled in the Punjab and less than 10 percent settled in the NWFP.11).10: FERTILITY DIFFERENTIALS BY PROVINCE EDUCATION LEVEL AND SOCIOECONOMIC STATUS IN PAKISTAN. and (c) international. overall illiterate women report substantially higher fertility than those who have completed even up to middle or higher levels of education.14-APR-03 . Urban areas of all the four provinces combined had 5 to 6 percent of their population classified as recent migrants. over 40 percent had originated in Punjab and over 37 percent in the NWFP (Table 2. 1986). INTERNAL MIGRATION With the help of information on duration of continuous residence.3 percent of the population.2 3.8 5. However. Pakistan Fertility and Family Planning Survey.2 3. Sindh PAGE 31 O F 95 . This difference could be due to inaccessibility to contraceptives by the poor. Continuation of this pattern has been confirmed by 1998 Census as well.7 4. the number of persons who migrated during the ten years preceding the 1998 Census was estimated at 4 million.7 4.Balochistan and NWFP.8 3. 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. as compared to 1. the percentage of recent migrants was about twice that of the other three provinces. Since the 1950s. In the rural areas of Punjab. 1. TABLE 2.1 4.0 3.1 5.3 Source: National Institute of Population Studies.4 5. which is clearly indicated when TFR is classified by the economic status of the household. Over two-thirds of these recent migrants settled in urban areas where they constitute 6. (b) rural to urban. the former on average having a TFR which is about one-third higher than the latter.6 3. 2000-01 G. 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. These are discussed in this section.7 5. Sindh has been receiving migrants who have mainly originated in the Punjab and NWFP provinces (Karim.5 percent in the rural areas. MIGRATION There are three main aspects related to migration in Pakistan: (a) inter-provincial. Of all those who had migrated within the country.6 4.8 4.

565.830 130.6 2.968 11.130.893 17.223 81.0 4.159 369. about four times of those who had originated within the province.599 originated in AJK /Northern Areas and 522.819 56. About 50 percent of those who originated in the NWFP settled in the Punjab and over 40 percent in Sindh.885 805.9 44. The urban population has grown over seven times from about six million in 1951 to about 43 million in 1998.4 467. Another important feature of migration during the past ten years is the pattern of intra.14-APR-03 .621. One-sixth of those settled in Punjab had originated in the NWFP and only 33 percent in Sindh.7 * -141.0 1.451 45.858** 100.9 14. The provision of basic amenities in urban areas has not kept pace with the growing PAGE 32 O F 95 . which is much higher and faster than in the rural areas.736 55.666 did not report their place of origin.12 rural-to-urban migration has resulted in an upward growth of population in the urban areas.074 154.6 23.645 6.and inter-provincial migration in the country.0 1. ** Additional 389. 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 urban population doubled 17.894 166. URBANIZATION AND GROWTH OF CITIES As shown in Table 2.0 0 Source: Population Censuses of Pakistan.743.2 7.11: DISTRIBUTION OF RECENT INTER-PROVINCIAL MIGRANTS BY ORIGIN. 1998 *Information on In-migration to FATA not available.083 -1.0 13.334 * 28.2 4.331 55.414 Pakistan 132.297 100. 2.847 -337.414 41.5 percent. Between 1951 and 1998.858 100. This phenomenon may contribute largely to the rapid pace of urbanization in the country.376 418.062 persons originated in other countries.7 percent to 32.235 3. On the other hand.0 1.883 -45.0 0.0 326. 108. 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.671 500. 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 73.0 5.176.439.130. over 75 percent of those originated in Sindh were settled in Punjab and less than 5 percent in the NWFP. 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.received the majority of these migrants.290 30.4 5. TABLE 2. This rapid urbanization has already resulted in Pakistan’s being the country with the highest proportion of urban population in South Asia.352.5 37.4 11.

4 -59. the rate of natural increase in the rural areas was 3 per cent per annum. 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.13.1 3. This implies that 0.0 -27.5 22. while the average rate of population growth during the intercensal period was only 2.6 2. during 1981-98.2 2. Apparently the rural areas of the country lost about 32 per cent of their population due to migration.0 -41.7 0.6 -31. the overall rate of natural increase in the urban areas of Pakistan was reported as 2.5 percent and during this period their combined population increased from 13. urban areas of the country.8 Pakistan 3.9 2. On the other hand.8 0.8 Balochistan 4. Based on the Pakistan Demographic Surveys conducted during 1984-97.urban population.6 0.7 -0.0 0.12: 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) -0.6 per cent.8 20.5 2.7 Percent (8)=(7)/(6)*100 (3)=(1)-(2) (4)=(3)/(2)*100 (5) Punjab Sindh NWFP 3.3 3. the twelve largest cities recorded an annual growth rate of 3.14-APR-03 .9 2.7 2.2 40.5 3.9 PAGE 33 O F 95 .8 2.3 3.8 2.9 3.0 3.1 2.6 1. adding to a host of problems through the increasing slums within cities and townships.7 23. or about 24 percent of the total urban growth was due to migration.6 -1. 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 1998.3 per cent.9 22.8 million to 24.5 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. on an average.3 2.7 2.8 percent.9 -0.6 -24. As shown in Table 2.2 percent higher population growth rate per annum than the rural areas. Table 2. recorded over 1.2 -0.

77 2. in the census count. 655 Inter-census Growth rate (percent) 3. Following the events and situation in Afghanistan in the post September 11. Sri Lanka and India as well. basic civic amenities remain scarce and the municipalities are unable to cope with the rapid increase in their population. those who emigrate unofficially are generally not accounted for.15.30 5. A newly established organization. suggests a substantial decline beginning from 1983 when it averaged about 120.9 1132. 3.000 by 1985 and then rose again to early 1980 levels.4 1166. It dipped to as low as 58. During the visit of an official Afghan delegation to Islamabad.9 1409. has begun the difficult task of registering refugees and unregistered aliens in the country.000 during much of the rest of the decade for which PAGE 34 O F 95 . 2001 period.8 1197. 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. The number of emigrant workers increased substantially during the early 1990s peaking at 191.14-APR-03 . as shown in Table 2.98 3. according to UNHCR sources.66 3. TABLE 2. and as a result of the Bonn Agreement between Afghan groupings in exile.2 million refugees are living in camps and another 2 million dispersed in the cities.52 Source: Population Census of Pakistan. It is estimated that about 1.000 in 1992 and remaining between 114.0 529. The Ministry of Labour and Overseas Pakistanis keeps records of all those workers who emigrate from Pakistan through official channels.000 Afghans re-entering Pakistan.694 Population (000) 1998 9339.000 persons annually. According to the statistics maintained by the Ministry of Interior. 1998 Census [note that totals are rounded].000 to 155.5 24. Based on the Ministry’s records.13: Rank 1 2 3 4 5 6 7 8 9 10 11 12 POPULATION OF TWELVE LARGE CITIES OF PAKISTAN.80 3. about 3. both the governments signed an agreement on the repatriation of about 3 million Afghan refugees over the next three years. However. There is a small number from Iran. led to the return of close to a million refugees to Afghanistan.0 5443.million. the National Alien Registration Authority (NARA).92 5. However. the trend in emigration. and other illegal aliens. the installation of the Interim Administration in Kabul. about one million people mainly from Bangladesh are believed to have also settled in the country. In the 1998 Census. Besides the Afghan refugees living in the urban areas.7 million Afghan refugees were living in Pakistan by the end of the 1990s.58 3.5 982. uncertain conditions in Afghanistan saw about 200. 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 13.94 2.60 3.50 3.71 1.8 565.4 421.43 2. In most of these cities.2 458. a conscious decision was made not to include Afghan refugees.5 2008.

there is evidence that a fertility transition has set in. However. Thirdly.4% of population is within the age group 10-19 years which underscores the need to meet the requirements of the adolescents. 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. three main conclusions can be drawn. semi-skilled and unskilled jobs and are a source of substantial inflow of foreign exchange. although population growth rate is high. there are variations in fertility decline: it is more in urban areas as compared to the rural areas. there is a trend of large scale migration to the cities in search of employment adding to the problems of poverty and urbanization.14-APR-03 . Secondly. The vast majority of Pakistani emigrants go to the various Middle-Eastern countries where they work at a variety of skilled. 23. and it is highest in Balochistan and NWFP as compared to the other two provinces. Firstly.data is available. Summing up. Lastly. fertility is significantly higher among those classified as poor and very poor. PAGE 35 O F 95 . from the foregoing analysis.

with the exception of o an indirect estimate of 533 per 100. about 5. 1991 Reproductive Health and Family Planning Survey of 2000-01 4 5 6 7 PIHS 98-99 National Institute of Population Studies. The community-based studies would suggest that the MMR in Pakistan ranges between 300 and 700 per 100. 1990)8.14-APR-03 . These studies also suggest that the levels and causes of maternal mortality vary between districts. Inspite of gradual decline of infant mortality in the country. Unfortunately. the perinatal mortality rate has remained high with no significant change. there is n reliable national MMR figure available in Pakistan. “Maternal mortality in an obstetric unit”.2 in 1970-754. 8 9 PAGE 36 O F 95 .69 %3. 2000-2001: Preliminary Report”. The average TFR for the last four years is estimated at 4.7.2). depending upon accessibility of emergency obstetric care (Table 3. J Pak Med Assoc 1985 Aug. About two-thirds of pregnant women receive no prenatal care7.4 million with an inter-censual growth rate of 2. However.5 million new births. A . Pakistan has an estimated 33 million women of reproductive age. resulting in 4.CHAPTER THREE REPRODUCTIVE HEALTH AND FAMILY PLANNING I. Almost 80% of births occur at home. and another study from Aga Khan University 3 Interim Population sector perspective plan 2012 Pakistan Fertility Survey. and 5.4 in 1986-915. for all of Balochistan (6. fertility is higher in the rural areas (TFR of 5.000 live births (Table 3. Two extreme examples are a study done in Civil Hospital Karachi in 1979-19839.1). depending upon the population they serve. usually attended by untrained birth attendants. The Total Fertility Rate (TFR) for all of Pakistan was recorded at 6. Hospital-based studies over-or under-estimate the MMR. according to PFFPS 1996-7). MATERNAL MORTALITY: Maternal mortality ratio (MMR) is considered to be one of the most sensitive indicator of women’s health and of the quality and accessibility of health services available to women.000 live births. 1976 Pakistan Demographic and Health Survey.000 live births (circa.0). MATERNAL AND INFANT MORTALITY 1.35(8):243-248. Each year. “Pakistan Reproductive Health and Family Planning Survey. Ahmed Z.86. REPRODUCTIVE HEALTH IN PAKISTAN Introduction: At Pakistan’s last census in 1998 the population was 132. which reported MMR of 2736 per 100.4 million women go through pregnancy and childbirth. A large number of these women suffer unnecessary risks associated with childbearing. indicating a high burden of disease and death.7) and among uneducated women (6.

obstructed labor and puerperal sepsis. 1993. Since independence. Midhet F. J Pak Med Assoc. Hamid R. 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. 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. Available data do not permit estimation of trends in maternal mortality levels. Table 3. 12 PAGE 37 O F 95 . “Contextual determinants of maternal mortality in rural Pakistan”. 43 (10): 208-212. 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. Moreover. Soc. Karim MS. “Causes of reproductive age mortality in low socioeconomic settlements of Karachi”. namely: postpartum hemorrhage. J Pak Med Assoc. toxemia of pregnancy. Med 1998. “Maternal deaths in a developing country: a study from the Aga Khan University Hospital.000 live births among booked clients during 1988-1999.1. Berendes HW. Lakha SF. MMR in various Pakistani sites. (46) 12: 15871598. Becker S. Pakistan 1988-1999”. be assumed that maternal mortality levels might have declined considerably over the last few decades.Hospital of Karachi10.14-APR-03 . 10 Midhet F. which reported the MMR of 20 per 100. particularly in the rural areas. however. Jaleel S. the decline in fertility may be directly associated with a decline in maternal mortality rate. Unfortunately. It may. 11 Fikree F. Berendes HW. therefore. 51 (3): 109-111. Karachi. particularly in the rural areas. there have been significant and considerable improvements in the access and quality of emergency obstetric care available to population. Sci. 2001. A small but significant percentage of maternal mortality is attributed to unsafe induced abortions. there are no hard data to substantiate this assumption.

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. 2. For example: the prevalence of severe anemia among pregnant women was about 10% in 198814. Proceedings of the First Annual Conference of Population Association of Pakistan. Hakim A. World Health Organization. small-scale studies and hospital-based information suggest high prevalence of anemia. Bhatti MH. 2000.2. 16 Ibid. Pakistan. Sci. suggesting high levels of maternal mortality. and only 18% of deliveries are performed by skilled professionals17. “Severe Maternal Morbidity at Pakistan Institute of Medical Sciences: The Near -miss Concept. Unfortunately. about 3. “Contextual determinants of maternal mortality in rural Pakistan”. rupture of the uterus and puerperal psychosis18. 2002 (under publication). 13 14 National Institute of Health. Med 1998. J. genital fistula. 17 Saleem. Pakistan Fertility and Family Planning Survey 1996-1997.5% of all deliveries conducted at the hospital’s Obstetrics Department were regarded as ‘near-miss’ – defined as a life-threatening obstetric emergency19. Soc. A Review of Research on Maternal Health. Available data point towards these indicators being poor. over 80% of all deliveries occur at home16. 18 Mehmood G. Berendes HW. Islamabad. Cause-specific MMR by access to emergency obstetric care (EmOC). The Aga Khan University and Population Council. In a study at the Pakistan Institute of Medical Sciences. 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. Islamabad. et al. Becker S. Cleland. an Indicator of Maternal Care”. Midhet F. (46) 12: 15871598. certain process and output indicators can be used for monitoring MCH interventions.14-APR-03 . National Nutrition Survey .Table 3. 1988. 1999-2001. Karachi. two-thirds of pregnant women do not receive any prenatal care15. December 1998. National Institute of 15 Population Studies. data on the prevalence and determinants of obstetric complications are scarce and unreliable. prolapsed uterus. Sarah. However. 19 PAGE 38 O F 95 .

State of the World’s Newborns: Pakistan. the quality of their product is not of standard. the perinatal mortality rate (stillbirths and infant deaths during the first week after birth) has also remained high – ranging from 56 to 72. A 15-days intensive Dais Training Program was developed and imparted in all rural areas of Pakistan. 2001-02 Save the Children USA. and about 53. therefore. Generally.14-APR-03 . 2001. Similar training programs were organized in other provinces. the reduction in the neonatal mortality rate was from 94 to 55 during the same period21. During 1992-1999. INFANT MORTALITY: Although infant mortality rate (IMR) in Pakistan has declined considerably since independence in 1947. based upon various small studies22. although many programs have reported improved knowledge. 21 22 Islam A and Malik FA. In 1996-7. a consistently high perinatal mortality rate indicates high levels of maternal mortality and low quality and accessibility of obstetric care available to women. it is believed that these programs failed to cause a significant decline in maternal mortality. 4. Pakistan has an IMR of 82 infant deaths per 1000 live births20. supervision or support system for the Dais trained under this program. MAJOR ISSUES IN SAFE MOTHERHOOD: During the 1970s and 1980s. Moreover. 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. 23 24 Health policy 1997 PAGE 39 O F 95 .000 traditional birth attendants were trained in safe delivery care and early recognition and referral of cases with common obstetric danger signs. J Pak Med Assoc 2001 June: 51(6): 218-222. skills and performance of Dais for sometime after training. oral re-hydration therapy for childhood diarrhea. there were about 2130424 trained midwives (including nurses) in the country. the emphasis of the national MCH program shifted more toward child survival strategies (growth monitoring.3. their quality of tutors. Because many risk factors of perinatal mortality are the same as those of maternal mortality. Sindh”. mainly because there was no follow-up. “Role of traditional birth attendants in improving reproductive health: lessons from the Family Health Project. The only alternative to traditional birth attendants is trained community midwives. the Family Health Project in Sindh again trained about 650 Dais in 10 districts23. Although most districts hospitals have midwifery schools attached to them. Even with a decline in the IMR. breastfeeding and immunization). 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. training. and. 20 Economic survey of Pakistan 20002-3 Integrated Household Survey – Round IV. the rate of decline is slow compared to most developing countries. The only major intervention directly related with obstetric care during this period was that of training a large number of traditional birth attendants (Dais).

Government health services in Pakistan are comprised of fixed facilities providing curative care. which have contributed significantly to the country’s experience in reproductive health and safe motherhood programming. social. 25 PAGE 40 O F 95 . many of these lessons arise from smaller scale projects that are implemented on a pilot basis. Some of these projects are listed here25: 1. physical. a significant proportion of high-risk pregnancies (such as those to grand-multiparous women). Women’s health cannot be improved without addressing each of these issues. This culture comprises predominance of traditional values. which has developed and tested a package of community-based interventions to reduce maternal mortality in a rural district of Balochistan. An operations research study similar to the BSMI is currently underway in rural Karachi. the results of which will be available shortly. Balochistan Safe Motherhood Initiative (BSMI) is an operations research study of the Asia Foundation.14-APR-03 . have little interest or faith in the government health system. and without moving from the traditional culture of birthing to a modern system of maternal and child health services. however the quality and sustainability of which is questionable. An ambitious national reproductive health services package is promoted. economic and cultural barriers to accessing and utilizing essential obstetric care. This is only an illustrative list and is not meant to be exhaustive. poverty and illiteracy. training Dais in recognizing and referring obstetric emergencies and setting up transport and telecommunication systems can significantly reduce perinatal. national level intervention programs should be based upon the lessons learned from the past. lack of faith in the modern medical system. Basic health units or rural health centers provide prenatal care or family planning. which encompasses almost all aspects of the national MCH program. in turn. EVIDENCE-BASED DECISION-MAKING IN SAFE MOTHERHOOD PROGRAMMING: Ideally. 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. Preliminary results suggest that providing focused health education to women and husbands. Emergency obstetric care (EmOC) is available only in district or Tehsil hospitals that are difficult to access for a majority of rural women. and there have recently been efforts to harmonize the field operations of the two ministries responsible for women's reproductive health needs. who. 5. poor access to health services. Pakistan has a specific traditional culture of birthing in its rural areas. beliefs and practices related to pregnancy and childbirth. poor nutrition. There is enough information available from various localized and regional studies within Pakistan that can be used to design large-scale interventions. neonatal and maternal mortality. 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. The government realizes these shortcomings. lack of awareness regarding MCH issues. Mechanism for monitoring the performance of government health facilities is weak. Many other important projects and programs (completed and ongoing) exist. Government health personnel are not accountable to communities. reliance on untrained traditional birth attendants and older women of the family for assisting in the delivery.

is currently implementing a project to strengthen EmOC services at secondary care hospitals in selected districts of Sindh province.2. Aga Khan University of Karachi has to its credit the only large-scale. UNFPA is assisting the Government of Pakistan in training selected Lady Health Workers from the National Programme on PHC/FP in midwifery skills. APPNA Sehat is another NGO that has trained Dais and provided health education to women and families in the Murree district of Punjab. In recent years. Preliminary results indicate a significant reduction in MMR in the project area. 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. 8. has incorporated Dais training and community health education in MCH in its primary health care project in rural areas of Sindh province. up-gradation of selected RHCs and THQs for basic and comprehensive EOC. 7. The catchment area of this worker would be 2000-5000 rural population depending on the geographical considerations. Their knowledge about where to obtain modern contraceptives is also quite high. multi-district community-based study of maternal and infant mortality. in collaboration with the UNFPA. training necessary staff and strengthening of district midwifery schools. 9. The MCH Department of the Pakistan Institute of Medical Sciences. FAMILY PLANNING Medicins du Mond. which was conducted during 1989-1993 in urban and rural areas several districts. 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. the Association has a wealth of data that can be used to evaluate their interventions. in collaboration with UNICEF. Islamabad. a NGO. 27 PAGE 41 O F 95 . 5. NIPS/IRD-Macro: Pakistan Demographic and Health Survey. B. Columbia University of New York. 26 NIPS: Pakistan Reproductive Health and Family Planning Survey. 6. 4.14-APR-03 . 10. Pakistan’s 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. there has been a substantial rise in knowledge about different FP methods. Ministry of Health in five districts. Even though the projects are not designed as operation research studies. 2001. The study was conducted in rural Punjab. HANDS. Pre intervention and post intervention baseline surveys (qualitative and quantitative) will be conducted in control and intervention areas. The results are awaited. The results are awaited. 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. has recently concluded its community outreach project that facilitated women’s access to EmOC through mobile clinics and training of lady health workers. developing a referral system. and 96% of currently married women are aware of at least one method26. Project will be implemented by the National Programme on PHC/FP. with an objective to increase health services utilization by women and improve women’s access to EmOC. and nearly 76% know a place for female sterilization versus only 37% in 1990-9127. In addition. 1991. the project will assist in community sensitization on maternal health. 3.

although it has a low demographic impact because the majority of women seek it after completing their family size (four or more children).0 3. nearly 45% of all acceptor couples rely on methods that require the initiative or compliance of husbands.1 1. 1991.9 4.9 16.5 6370 Results of the five studies reveal increasing use of all modern methods.8 1. The less effective traditional methods of family planning are also quite popular. This is an interesting finding and is discussed in some detail below.5 0. 29 30 PAGE 42 O F 95 .6 0.7 2. the facilities and community-based distribution systems of the MOH and MOPW offer oral contraceptive. 1996-97.4 1.3 6364 PCPS29 1994/95 17.4 1.3.6 3.0 5. while IUD also makes an important contribution. two types of injectables.7 3.5 2.8 0.0 0. Pakistan Fertility and Family Planning Survey.0 1. CONTRACEPTIVE PREVALENCE Among modern methods.0 1.6 5.4 0.0 7.2 6.1. 28 Pakistan Contraceptive Prevalence Survey 1984-85 Pakistan Demographic and Health Survey.2 0.8 12.0 0.6 0.2 1.1 4.1 0.0 7.0 0.9 0. closely followed by withdrawal.2 7922 PFFPS30 1996/97 23.7 1. According to the PRHFPS survey 2000-01. condoms and voluntary surgical contraception.1 2.6 20.14-APR-03 .0 5.2 1.5 7405 PDHS 1990/91 11.6 0. Female sterilization remains the method of choice.8 9.9 1.6 0. 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 9.9 0.6 1.1 2.5 7582 PRHFPS 2000/01 27.3 1.5 6.3 0.0 0. The following Table shows the progression in the use of contraception since 1984.7 5.0 2.9 3.5 0. The most popular temporary method is the condom. one type of IUD.0 4.1 7.8 0.6 0. Table 3.0 2.4 0.3 0.

The USLS found that contraceptive continuation rates for condom. 31 Miller PC.32 hypothesize that this may be a result of only those couples using the modern contraceptives who are resilient and determined to use them. and this disagreement cannot be regarded as sole explanation for unmet need 36. “On the Dynamics of Contraceptive Use in Pakistan”.722 women). could be the main reasons that can explain both the high levels of unmet need and relatively high rates of use of traditional methods. In 1997. 1997 Ibid.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. especially with regard to sexual relations. which reported the findings from a national sample of 2. and (2) the economic. perhaps with influence from the husband. lack of faith in the health and family planning delivery systems. including those reporting the causes of high unmet need of family planning 33. 35 36 PAGE 43 O F 95 .14-APR-03 . including 12. Ibid. 2. respectively)31. continuation rates for the pill and injection users were much lower (55% and 46%. Women having surgical sterilization were quite satisfied with the method.9% who wanted no more children. et al. the contraception use continuation rates for modern contraceptives were high as compared to other developing countries and were certainly within international norms. studies have revealed little inter-spousal disagreement between husband and wife on fertility issues. Population Council. UNFPA commissioned the Population Council to conduct the User Satisfaction and Longevity Study (USLS). and were closely comparable with those for IUD. withdrawal and periodic abstinence were between 75 and 80 percent at the end of the first year. 1999. UNMET NEED OF FAMILY PLANNING: The survey of NIPS34 reported a total unmet need of family planning of 33%. 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. as perceived by women35. Contrary to popular beliefs. This hypothesis is supported directly or indirectly by many other studies. Many users of female methods complained of negative effects. Interestingly.1% women who wished to delay their next pregnancy and 20. Generally. social taboos against the use of family planning. A distrust on modern methods of contraception. provider behaviour. “The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women” Population Council. 32 See. Miller et al.. Sathar and Casterline. 1997. lack of follow-up services. etc. including those relating to menstruation and sexual relations. “The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women” Population Council. Fewer women reported similar complaints related to natural methods. for example. 33 34 Pakistan reproductive health and family planning survey 2000-2001. social and physical costs of using modern contraceptive methods. perceived or real fear of undesirable side effects.

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 Pakistan’s 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 Pakistan’s 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 Welfare’s 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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Zaidi SH. Sankaranarayanan R. A majority of patients did not receive adequate treatment. (Department of Oncology. These findings indicate that genetic predisposition plays a greater role in the causation of ovarian cancer in Pakistan. Hassan SH.85(3):325329. Among women.52(4):155-158. Gan To Kagaku Ryoho 2002 Feb.Adequate data are not available to estimate the incidence and age-standardized rates (ASR) for cancer among men and women in Pakistan. (National Cancer Institute Karachi): “Clinico-pathological features of breast cancer in Pakistan”. (Dow Medical College and Karachi Cancer Registry. Bhurgri A. Karachi): “Cancer incidence in Karachi. Sana S. as compared to Western countries. A study of over 3. 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. Thus it is both preventable and Bhurgri Y. National data on infertility is not available. Pakistan: first results from Karachi Cancer Registry.000 for men and 163/100. J Pak Med Assoc 2002 Apr. Secondary infertility is associated with unsafe abortion and reproductive tract infections.4%. Another study42 in Karachi found that patients of breast cancer present at a very later stage as compared to the Western countries. 41 Malik IA. All these factors contributed to poor cure rates among cancer patients in Pakistan. INFERTILITY: In Pakistan infertility is usually held to be the wife’s problem. including a high prevalence of family history of young age breast and/or ovarian cancer and a younger age at presentation. 43 PAGE 47 O F 95 . Associated co-morbid conditions were a major cause in delay in cancer treatment. 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. the reason for not contacting a medical care provider included poor socio-economic status and illiteracy.000) and ovarian cancer (ASR = 10/100. breast cancer was the commonest (ASR = 52/100.52(3):100-104 42 Aziz Z.000 for women. 40 Malik IA. About 93% of the 506 patients studied over a period of five years (1994-1999) had discovered the lump in the breast accidentally.14-APR-03 .000).000 confirmed cancer patients in Lahore43 determined that a majority of the patients presented at a relatively advanced stage. Small-scale studies estimate that prevalence of primary infertility is 3.” Int J Cancer 2000 Feb 1.000). AI Medical College Lahore): “Cancer treatment in Pakistan: Challenges and obstacles”. Epithelial ovarian cancer patients were found in one study41 to have unusual presenting features. particularly STIs.29 Suppl 1:4-8. (National Cancer Institute Karachi): “A prospective study of clinico-pathological features of epithelial ovarian cancer in Pakistan”. 3. followed by cancer of the oral cavity (ASR = 14/100. which found the rates of 137/100. The only study on incidence of cancer was conducted in Karachi South District40. Rahim A. Parkin DM.4% and secondary infertility 18. J Pak Med Assoc 2002 Mar.

activities and responsibilities that occur as individuals move from childhood to adulthood distinguish adolescents as a formative time with significant consequences for individuals. Hakim A and Z. Serious attention to adolescents in Pakistan should be accorded due to their large (and growing) numbers. communities. expectations. A DETERMINANT GROUP: ADOLESCENTS The realization that adolescence is a separate stage in life has acquired attention only in very recent times. and is a complex phase of physical. the transformation in social roles.13 mill) in 1998 constituted 23. the diagnosis and referral of infertility cases is also very low in Pakistan.14-APR-03 . The adolescent population 10-19 (30. mental. In: Pakistan’s Population Issues in the 21st Century: Proceedings of the Annual Conference of Population Association of Pakistan. 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 .Durrant.3% of the total population. This cohort is estimated to increase by 9. and the country46.between the ages of 10 and 19. Adolescence is defined as the period of transition from childhood to adulthood. due to the population momentum built into the current age structure. Though adolescents is most often associated with physical changes accompanying puberty. Zahir “Reproductive health indicators in Pakistan: Experience of a pilot study”.23 mill by 2010. In a small study in Jhelum District of Punjab. families. 44 45 Population Census 1998 46 Adolescent Girls and Boys in Pakistan: Valerie L. Karachi. and social maturation. This figure will continue to grow. Pakistan currently has the largest group of adolescents in its history with nearly 30 million individuals45 – almost a quarter of its population . emotional.10 mill to a total of 39. E. However. Population Council December 2000 PAGE 48 O F 95 . 2000.often treatable. as will the proportion of the population represented by adolescents. the total prevalence of infertility was estimated at 13% (15% in urban area and 10% in rural area). occurring during the second decade of life.

79 million. This cohort is estimated to increase by 13. Adolescent marriage particularly among girls is still common in Pakistan. by the year 2010. 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.5 and has leaped from 23. there will be an increase of 7.13 million) in 1998 constituted 23. However the age of marriage has been rising in the past few decades.56 million to a total of 42.54 million) in 1998 constituted 43% of the total population will increase to 62.25 million in absolute number but would be decrease by 6.25% in relative percentage of the total population. In the age group 15 – 19 years 3 to 4% of males and 17% females are married. The singulate mean age of marriage (SMAM) has increased from 16.7 in the 1960s to 22 years in 1998 for girls. The women in reproductive age 15-49 (28. while in the 20 –24 years age category 17 % of males and 54% of females are married.10 million to a total of 39. 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 PAGE 49 O F 95 . Thus.48% of the total 2010 population.3 in 1961. A clear gender difference remains in the timing of marriage. It is estimated that the population of Pakistan will increase to approximately 171 million by the year 2010.23 million with a relative decrease of 0.36 million with a relative increase of 2.14-APR-03 . This cohort is estimated to increase by 9. For boys the current SMAM is 26.38% of the total 2010 population. Likewise the adolescent population 10-19 (30. A closer look at the married adolescent population in Pakistan reveals interesting findings. There is also an urban/rural difference in adolescent marriage practices.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. The 0-14 cohort (55.8 million) in 1998 constituted 22% of the total population.32% of the total population.

The Government of Pakistan’s National Health Policy 2001 promotes primary and secondary health care services. Similarly. a strategy was adopted in the First Five-Year Plan (1955-60) by introducing family planning on a limited scale through voluntary organizations. Later. During the Second Five-Year Plan. and the Government’s resolve to support the population program. POLICY FRAMEWORK In Pakistan. contraceptive prevalence is extremely low in married adolescents with 22% reported unmet need. The plans continued to highlight the consequences of rapid population growth on social and economic development. To improve the fertility regulation and contraceptive utilization among married adolescents. Part-time doctors provided clinical contraceptives and sterilization services. the education as well as population policies and strategies do not address and encompass sex education or reproductive health programs for adolescents and youth. According to PCPS 1994-95 only 5% of married girls aged 15 – 19 years had ever used any method. Dais (traditional birth attendants) were used for door to door service delivery and motivation. Accordingly. Lowering population growth rate has become a permanent feature of 5 -year plans.14-APR-03 . an independent family planning infrastructure was created and mass scale IEC activities were launched and service delivery network established. THE OFFER OF SERVICE S A . Regarding fertility and family planning. a) Population policy framework Pakistan recognized long-term consequences of high population growth rate for its future socioeconomic development in early the fifties. traditional or modern where as in the 20-24 year age group the contraceptive use is about 17%. Young girls are not supposed to have any information on reproductive health. family planning services were provided through the health infrastructure. 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. 47 Women are taught chastity and it is expected that once married they will automatically understand reproductive health. 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. Their access to information and tailored services for their age group should be enhanced in order to serve their unmet needs. II. their attitudes towards contraceptive use and childbearing choices should be adequately explored. 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. PUBLIC SECTOR 1. it is considered a social taboo to talk to them.services. 47 ibid PAGE 50 O F 95 .

In fact. hakeems and homoeopaths was envisaged. IUD and Injectable along with provision for maternal and child health services through program outlets. resource allocation and regular reviews as part of a social sector undertaking. The rural coverage increased by extending the scheme of VBFPWs to all the districts of Pakistan. Review of the program was made a regular feature at all levels. A special IEC program and quality service facilities were developed for large cities of the country. the program received open and sustained political and administrative support. Parliamentary Group on Population and Development was constituted in the National Assembly wherein various resolutions were passed in support of the program. major policies of the Sixth Plan were followed with emphasis on lowering fertility level. restoration of more effective IEC campaign. seminars. Publications and give-away items were widely distributed. Social Marketing of Contraceptives program was introduced and National Institute of Population Studies was established for undertaking research on population and development. In addition. The scheme was experimented to improve low coverage in the rural areas. National Assembly and Provincial Assemblies. From 1975-80.14-APR-03 . Involvement of NGOs was streamlined by establishing National Trust for Population Welfare (NATPOW) with financial and operational autonomy. experimentation of the village-based family planning workers scheme in eight districts of the four provinces.During 1970-75. the program operated at a low key due to reorganization. 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. supervision and improve co-ordination at the implementation levels. registered medical practitioners. shift towards more effective contraceptive methods. association of the Private sector through the Social Marketing Program. In order to elicit broad-based support from the public representative Standing Committees were set up in the Senate. Both the schemes together have enhanced the coverage in the rural areas. group meetings. such as sterilization. and approach of the program was made broad-based by adopting a multi-sectoral and multi-dimensional strategy. Studies undertaken by the Population Council and NIPS reveal that contraceptive prevalence have doubled in the villages where these workers have been deployed. a major administrative reorganization was undertaken. This was to be achieved by pursuing multi-sectoral approach. and awards for writing on population issues were institutionalized and implemented. Political commitment became visible and PAGE 51 O F 95 . political unrest and suspension of IEC activities. The program was backed by sustained promotional campaign through mass media and supportive events and activities with the involvement of private sector. the breakthrough in the program occurred during the later part of this Plan (1988-93) with open and sustained political support. During the Eighth Plan Period 1993-1998. continuous motivation system (CMS) was introduced by employing male-female team of workers at union council levels. Simultaneously. In addition Divisional and Tehsil tiers were created to strengthen monitoring. open motivational campaign. participation in national conferences. In 1981. expansion in service delivery infrastructure including mobile service units in the remote areas. 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. Meet-the-Press sessions. exception from budgetary cuts. During the Seventh Five-Year Plan period 1988-93. with a view to set trends for rural areas to emulate. Greater involvement of NGOs. Field activities were provincialized. increase in allocation of funds. the Ministry of Health also launched the Lady Health Workers Program of Primary Health Care and Family Planning.

. In 2000.6 percent in 2002 while CBR touched a level of 29 births per 1000 of population in 2000.8 in 2000 is a big achievement. the merger of village based family planning workers and lady health workers was agreed to place under the Ministry of Health in September 2002. Therefore.14-APR-03 . ensuring continuity and consolidation of the gains. Reduction in the fertility of younger age groups while looking at the age specific fertility rates is more pronounced in the following table. and predominant position of health infrastructure in terms of its vastness. This proposal was submitted to the Chief Executive on 6th April 2001 and was approved.1 percent as set in the Ninth Five Year Plan. The involvement of health outlets will help to decrease unmet need and increase the family planning coverage.e. the population growth rate recorded a decline to 2. which has shown an increase reaching 30 percent by 2000 from 12 percent in 1991. The current Ninth Five-Year Plan 1998-2003. once again the contraceptives were supplied to the Provincial Health Departments. This shows a 2% percentage point increase per year. rising age at marriage and desire not to have large families are important reasons for adoption of family planning in Pakistan. 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.4 in 1991 to TFR of new low level of 4. Similarly.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 impact assessment shows some progress on selected indicators such as CPR. The decline in TFR indicates a reduction of 2 children from 1975 to 2000. The Chief Executive in his address on 11th July 2000 directed to achieve a population growth rate of 1. The Group recommended that all the health outlets should provide family planning services as part of their duties. PAGE 52 O F 95 . Later. Reduction of more than one child i. it was proposed by the Review Committee to involve all health outlets to provide full range of family planning services. is guided by the principle of building on positive elements of the on-going program. The change in educational attainment by women. TFR of 5. The declines in TFR during the last decade also documents the achievements of the Population Welfare Program. In view of the paradigm shift to reproductive health and family planning. The following table depicts the observed TFRs during the period. In accordance with the Chief Executive’s orders and the decisions of the Task Force reviewing the Population Welfare Program’s performance. A broader reproductive health approach is being pursued with emphasis on mother and child health care.9 percent per annum by 2003 instead of 2. The environment was changing fast in favor of realization of the need to moderate fertility to contain population growth rate. The scope and outreach of the program is being enlarged through enhanced and improved service delivery strategies with continued attention to rural areas. 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.

for provision of service to remote and underserved areas. The Population Policy aims at involvement of males in the decision-making of family size. efforts towards demand generation. religious hindrance. joint efforts of private and public sectors. and Federal Bureau of Statistics.4. the period of 1990-2002 has seen the announcement of three health policies. b) Health policy framework In the health sector.Table 3. Agenda for Health Sector Reforms. The proportion and level of unmet need for family planning is one of the highest in the developing countries. December 2001 PAGE 53 O F 95 . In addition the government has announced several policy statements on MCH and FP on various occasions.3 TFR 6. 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. Pakistan Reproductive Health and Family Planning Survey 2000-01. increase in coverage and access to family planning services. a quality of services. Age Specific Fertility Rates (ASFR).14-APR-03 . The factors that act as obstacles to the use of contraceptives are: husband’s disapproval.4 4. 48 National Health Policy 2001. Despite the recent sharp increase in contraceptive prevalence during the 1990s. 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. human resource development. 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 45-49 104.8 Source: NIPS. Pakistan Demographic Survey 2000. and regular monitoring and technical supervision. 1) health sectors investments as part of Government’s Poverty Alleviation Plan. unmet need for family planning remained high. The new policy has three key features.27 5. One of these has been the Reproductive Health Package of 1999. The latest is National Health Policy 2001. which was a joint document of the Ministries of Health and Population Welfare. involvement of partnership and with NGOs. 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 . the overall vision for the health sector is based on “HealthFor-All” approach.

however. This is reflected partly in the delineation of MCH in defining strategies for all policies. 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. programs and packages have emphasized maternal health. In 1990.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. a strategic plan of action is lacking. research and evaluation. After defederalization the Federal Ministry is now responsible for policy. safe motherhood. 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. procurement and supplies. international coordination. 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. While the need for female paramedics has been mentioned. Concrete steps could not be delineated for addressing nutritional issues like maternal anemia. 2. promoting public-private sector partnership. planning. Yet the size. In 1976. capacity building. setting standards and protocols. and availability of female paramedics and health workers. and resource allocation. January 7-9. The priority areas of the health policy with reference to child health have been immunization. it was upgraded as an independent Ministry of Population Welfare. child malnutrition. monitoring. All polices.14-APR-03 . an overarching comprehensive MCH framework to address the issues being faced by the population is lacking. policy support to non-governmental organizations. 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. Pakistan’s strategy on reproductive health has roots in the population control program. the structure and the organization of the two Ministries are vastly different from each other. However. infant health care and childhood illness. 49 A Critique of MCH policy in Pakistan: Implications for the future. the gaps in health policies with reference to safe motherhood are49 : § § § § § All policies have included various components of MCH agenda. family planning. RH and HIV/AIDS and STIs have received progressively increasing emphasis in all policy documents since 1990. 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. advocacy and IEC. contraceptive forecasting. stunning and wasting that have major influence on the health of women and children. 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. 2003 PAGE 54 O F 95 .

The organization and performance of various facilities is described in some detail below. 1993. 3 – 5 clients per day) and that the staff lacked training in counseling skills. About half of the clients visiting the RHS Centers came for contraceptive surgery and the remaining half to get other contraceptives. including pills. 4. A later study has found frequent stock-outs of contraceptive supplies at many Centers53. including the Reproductive Health Services Centers (RHSCs). “Evaluation of Mobile Service Units. each MSU is expected to organize 10-12 camps each month to provide curative care and family planning services. “Situation analysis and users’ survey of Reproductive Health Services A Centers”. While their area of coverage is small. 52 Population Council: “A Study of the operations of the contraceptive logistic system of the Population Welfare Program”. and about 1. Client satisfaction levels ranged between low to medium. NIPS.000. equipped and managed by the MOPW. MOPW operates 131 MSUs. the Family Welfare Centers (FWCs) and the Mobile Services Units (MSUs). The Ministry operates 275 RHS Centers for providing contraceptive services. and are staffed. PAGE 55 O F 95 . which provide RH services in remote rural areas. the MSUs’ performance is quite satisfactory. 53 54 Hakim A.688 have been established. Some of the other problems included frequent breakdown of vehicles. 50 51 Service statistics of MOPW. Each MSU serves a population of about 30. et al. it seems to have reached a plateau afterwards50. Type “A” RHS Centers (numbering 106) are located in their own buildings constructed on the premises of public sector hospitals. on the average. lack of coordination with community leaders and staff absenteeism. et al. injectables. although there were complaints about the high price of contraceptives provided by the MSU. Their main function is to provide temporary methods of contraception. 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. A 1993 study of the functioning of FWCs52 found that the Centers were under-utilized (serving. FWCs are the most basic outlets for family planning and reproductive health services in urban and rural areas. A National Institute of Population Studies (NIPS) study51 found that the clients were generally satisfied with the services provided at the RHS Centers. there are 1300 male village based family planning workers for motivation and community mobilization. IUDs and condoms. Type “B” RHS Centers (169 in number) are located inside selected government and private hospitals. et al.The MoPW. Besides. While the annual number of clients for contraceptive surgery steadily increased from 1993 to 2000. Population Council Working Paper Series No. Managed and supervised by a Field Technical Officer (FTO). Population Welfare Program”. 2001. through its provincial Population Welfare Departments (PWDs) provides services at its own facilities. NIPS Islamabad. 25 percent of MSU in charges are not making follow-up visits and 23 percent MSU in charges have no vehicles. “A Situation Analysis of Family Welfare Centers in Pakistan”. Cernada GP. 2001 Hakim A. April 1998.14-APR-03 . 21 percent of MSU had no proper arrangement for privacy. 2001.

At the community level. Women Health Project. monitors and evaluates whereas the provincial departments of health and district health offices carry out the actual implementation of the Programs/ projects. The patient-load on public health facilities varies greatly. which are the remnants of the earlier experimentation of providing a national health system. coordination. few weaknesses of the Program include: (1) LHWs are seriously undersupplied with drugs and contraceptives. MoH designs National Programs/ projects in collaboration with provincial departments of health. some preventive services and referral to the next levels of care. during 1990s. Clients expect free consultation and free medicines. 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.14-APR-03 . evaluation and research. health facilities bearing various other titles also exist. 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. Virtually all clinical staff members are involved in some kind of private practice. The Programme is exclusively an attempt to provide basic RH services and information to women at their doorstep. Services are provided either free of cost. National EPI Programme. In practical terms. The only preventive services provided at the primary health facilities are maternal and child health care and immunization. or at minimal charges. These hospitals are located in the major urban centers and are usually attached to medical colleges or other post-graduate medical institutions. the MOH/DOH owns and operates the largest number of tertiary care hospitals in the country. important initiatives of MOH are National Programme for FP & PHC (the LHWs’ Programme). role of Ministry of Health is policy development. Most staff members are unclear about their job description.3. Teaching hospitals are usually over-crowded. At the primary level. Finally. the National Programme for FP and PHC is the most promising large-scale intervention of the MOH. such as: Sub-health Centers. health services have significantly improved and expanded. They provide health services to the general population and nobody is denied these services for any reason except non-availability. 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. all primary health facilities mainly provide outpatient curative care. also transport for supervisors. Additionally. The primary aim of the health facilities under the MOH/DOH is the provision of curative care. arranges necessary funds. In addition. However. the Tehsil and District Hospitals provide specialized services and inpatient care. MNT special immunization activities. collaboration with International agencies and provision of services through federal health institutions. depending upon the nature of services provided. monitoring. and (4) lack of training of LHWs in delivery care and newborn care. regardless of their level. while most peripheral facilities in the rural areas are underutilized. (2) Services are limited in health facilities to which patients are referred. the concept of ‘National Programs’ materialized and proved to be successful. (3) Need to increase effectiveness of supervision. provide technical assistance. National AIDS Control Program. 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. PAGE 56 O F 95 . MINISTRY OF HEALTH In the health sector. Lack of female doctors and paramedical staff is another serious problem in all rural health facilities. National Nutrition Project and Reproductive Health Project Since independence in 1947. Independent evaluations of the Program are generally positive. Each year. under-staffed and under-funded. In reproductive health. Civil Dispensaries and Civil Hospitals.

879 Maternal and Child Health Centres. and over one third of current users of modern contraceptive methods get their supplies from a government hospital. Lack of female doctors and paramedical staff is another serious issue in all rural health facilities.230 Basic Health Units and 4. adoption and implementation of this strategic document has not made much progress. 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). contraceptive and supplies are common problems.14-APR-03 . MOPW would retain the responsibility for strategizing and planning the country’s 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. obtaining the supplies from the MOPW. MOH/DOH has always provided some FP services at its facilities. It may be noted. shortage of funds and disrupted donor support. and will be a member of the District Health Management Team (DHMT).625 Dispensaries). partnerships with private sector and networking with civil society. which can be used to facilitate implementation of the national population welfare program. however it has not yet been fully operationalised. which took place in Cairo in 1994. PAGE 57 O F 95 . 5. In each district a Deputy District Officer Health (Preventive/ Reproductive & Child Health) will be in charge of reproductive health and population welfare services. which will also include the District Population Welfare Officer. Staff absenteeism. inadequate timing of operation and stock-outs of medicines. which he/she will implement through the integrated network of BHUs and RHCs. and only an undetermined small percentage can actually provide a full range of family planning services to its clients. He/she will work under supervision of the Executive District Officer (Health). 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. According to the recent Population Policy. Implementation of the ICPD Program of Action has been slow mainly due to lack of commitment.Under the recently introduced devolution plan. The Departments of Health have a vast network of health facilities (907 Hospitals. 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. a National Reproductive Health Services Package was developed and adopted jointly by the Ministries of Health and Population Welfare. Of late. there has been a renewed emphasis on harmonization and integration of health and family planning services. In 1999. However. Although a National Steering Committee on Reproductive Health was formed u nder the Ministry of Health two years back. 4. with MOH/ DOH facilities and workers supplying about 61% of all government services for family planning. implementation of the reproductive health activities is the responsibility of the districts. 541 Rural Health Centres. however. This will be achieved through Population Welfare Program’s infrastructure and through the health service delivery infrastructure. that not all of these facilities are fully operational.

The opportunities include more equitable distribution of services and resources. monitor health outcomes. The Provincial Governments are responsible for ensuring implementation of national policy ensuring access and equitable distribution of services. b) Devolution and Reproductive Health Services During 1980s and 90s.14-APR-03 . but there are also major risks. Finally. Secondly. It is envisaged that the districts will increase the effectiveness of health and population service delivery by opening up a range of opportunities. The Federal Ministry of health is responsible for development of the health policy and providing guidance to ensure effective implementation. None of the reforms represented major changes to the basic model of provincial centralization. planning and implementation mechanism. 2002) 55 PAGE 58 O F 95 . The Federal Ministry of Population Welfare presently manages the Population Welfare Program with responsibility of policy. 55 Most of these efforts had little impact due to short life span of these reforms. gives job-descriptions and expected performances of various health and family planning workers and streamlines the joint and separate roles for the two Ministries. national and provincial representatives on the one hand and district Nazims on the other will impact on the success of the devolution plan. 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. the health sector has not been subjected to major organizational or management reforms. management and financing. the ownership and complete adoption of Population Policy by the provincial and district health d epartments is still to come about. and finance and provide technical leadership to key preventive health programs. 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. reducing mal-practices such as staff This and the following has been taken from the Aide Memoire. The provincial governments are responsible for implementation. The relationship between the local. The program is undergoing a significant organizational changes due to defederalization of the program from the federal to the provincial governments.There are many challenges to the implementation of the above policy. there are the expected problems of transition from the federal to provincial implementation. It can thus be used as a framework for future collaboration between the two Ministries. The Government of Pakistan’s 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. World Bank Mission with DFID and ADB (October 12 – October 28. The National Reproductive Health Services Package (NRHSP) clearly defines the priority areas for intervention in RHS. The Population Welfare Program is also being devolved to the district governments. provision of technical guidance for preventive health programs and monitor health sector outputs. management of specialized and tertiary care hospitals. The Districts are responsible for management and implementation of health services including transfer of resources from provinces to the districts. medical education. Firstly.

the staff capacity is adequate. Besides many other issues. Major challenges are to establish institutional structures for development of effective District Health Management with clarity of roles and responsibilities between provincial and district. Female medical officers. BHU. underutilized and of low quality. Most of them are exposed to PHC activities during their postings at the first level care facilities. under all the circumstances. and community-based workers are the primary service provider to the children and women within the health sector. they are not allowed to conduct delivery at the centers nor are they recognized by the Pakistan Nursing Council to undertake midwifery practice. Male to female staff ratio is 7:1 in the field. the service delivery is inadequate. 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. and that flexibility in personnel management is sufficient to plug skills gaps. improving monitoring of services and providing feedback to lower levels of health care etc.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. c) Human Resource Development Within the ministry of Population Welfare the backbone of service delivery is the cadre of Family Welfare Workers. increasing expenditures on key non-salary inputs to improve quality of services. and that their knowledge of diagnosis. According to one survey around 21% of the facilities did not have a female staff56. However. the District Health Management Teams are empowered sufficiently to ensure equitable distribution of resources and effective and efficient use of available funds. there are 56 PIHS – Round IV A situation analysis and recommendations for evidence based approaches. LHV. It has been observed that generally there is irrational use of antibiotics and other medicines. They are mostly reluctant to serve at these facilities due to lack of security. treatment. HIV/AIDs and MCH services are addressed and ensure that a monitoring system is place to track results and outputs. it is a common view that despite excellent infrastructure for health. immunization. Besides this she prescribes medicines for general ailments to children and the women. However. Midwife despite being the lynch pin in providing obstetrical first aid is one of the neglected and misunderstood profession in the country. MCH consultation 7-9 2003 57 PAGE 59 O F 95 . According to the National Health Policy 1997.absenteeism through increased local accountability through local community representatives. the availability and quality of female service provider is the most important contributing factor to poor status of MCH indicators in the country. adequate.14-APR-03 . low salary. the local policy priorities and preferences emerge but national/provincial priorities such as family planning. However. These workers are trained for 18 months in family planning and MCH services including safe delivery. dosage and side effects management requires much improvement. midwives. RHC and MCH centers form the main stay of the preventive and curative care through static health facilities. ensuring that financial flows are predictable and. lack of civic amenities and less opportunities for professional growth.

However. The last revision of curriculum took place in 1994. LHVs were primarily supposed to provide PHC and domiciliary midwifery services by visiting households in the communities.21304 midwives in the country (including nurses) but their exact whereabouts and presence in the community is not known. The concept of Lady Health Visitor (LHV) was proposed in the first Five-year plan 1955-60. its coverage currently is around 3040%. when it was decided to increase the number of MCH centers in the country. lower salaries and lack of civic amenities. there is shortage of staff especially the female staff which really matter in case of services to women and children. there is no definite career structure for this midwifes once she acquires the license. They expect provision of free medicines. poor accommodation. Even at the static health facilities. Pupil midwives are trained at the midwifery schools which are mostly attached to the district hospitals. Most of the first level care facilities and district hospitals are used by the low socioeconomic class of the population. LHVs and midwives differ in their job description and background but the curriculum being used is the same for the two categories. 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. Most staffing issues pertain to the area of primary and secondary level care. LHVs conducted only 3% deliveries in the country. However. 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.14-APR-03 . d) Quality of services Government of Pakistan invested heavily in the infrastructure for health and population during its fifth five year plan. still there is a persistent shortage of female staff in health facilities. LHVs are unable to provide EmOC services round the clock due to the shortage in number. Although introduction of community based workers has proved to be a very successful scheme. According to the PIHS survey 1996. However she remains the main female service provider to women and children at the first level care facilities. majority of them work for the private sector and there is no mechanism for assessing their quality of services. however. lack of quality assurance mechanisms and minimum exposure to hands on training. This becomes even more crucial when a large number of the experienced professionals are retiring in MOPW in the near future. shortage of equipment and out of facility private practice. a practice which is no more followed. Similarly these facilities are not equipped well enough and in some cases where equipment is available. wide gaps in the quality of services remain which are highlighted below. Further. 22% respondents did not use the rural health facilities for lack of medicines. the staff is not there or they are not trained in its use or there are not enough PAGE 60 O F 95 . As mentioned earlier. Women medical officers are reluctant to work at the first level care facilities for want of security. Although the public health nursing schools training this cadre has increased from 10 in 1994 to 23 in 2000. Sixth to eighth five year plan tried to address the issue of human resource at the facilities and community. According to PIHS 1996/97. the standard of this training is highly doubtful due to shortage of trained staff. contraceptives etc at these outlets. Female paramedics are short in number and their training is not well regulated and monitored for quality.

In recent years availability of contraceptives to the outlets of MOPW has improved considerably. As a result UNFPA was hard pressed to meet contraceptive requirements. distribution and monitoring. investing over 40 percent of its country program allocation for the procurement of contraceptives. switching to other methods and removal of IUDs. DOH and National Programme also should be strengthened by incorporating indicators regarding discontinuation. There is need to develop tools and instruments by which the information could be used for improving the management of inputs. 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. District managers are not empowered through management skills and delegation of administrative and financial authority. coupled with less capacity at the district levels for monitoring and supervision is one of the major contributory factors to low quality of services. e) Logistics and availability of contraceptives Throughout the 1990s. In the above mentioned PIHS survey only 33% basic health units were located within five kilometer. Even these facilities are not women-friendly due to lack of privacy and proper sitting arrangement. Lady Health Workers of the National Programme also faced stock out of condoms and oral pills during the year 2000 and 2001. DFID and KfW. Until the year 1987. unfriendly environment and poor location. UNFPA. Supply of contraceptives to the programme has been recently restored through UNFPA PAGE 61 O F 95 . the major sources of funds for the supply of contraceptives to the Population and health sectors were the donors including USAID.funds available for its maintenance and repair. The information collected is not fully analyzed at these levels and mechanisms for feedback are not functional.14-APR-03 . organized sector like WAPDA and NGO outlets in the districts. Weak accountability of services and outcomes. Another grey area is the issue of accountability. Perhaps constraints in resources available to district staff also play its part. The Ministry of Population Welfare maintains one central warehouse at Karachi from where contraceptive are supplied to all the public sector. increasing prevalence by modern methods is essential to its development goals. One of the reasons was lack of commitment by the District Health Managers for providing family planning services. Since July 2002. 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 contraceptive requirement has been conservatively estimated to cost around $15 million in 2003. monitoring and supervision. 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. the supplies of contraceptives have again started through the Provincial Health departments. process and measuring output. smooth supply of contraceptives to DOH could not be ensured. The other main reason was the issue of contraceptive pricing which will be further discussed later. and their outlets are now providing FP services. LMIS of MOPW. Technical assistance is also required in the areas of logistics and management information systems (LMIS) training. However. Ministry of Population Welfare (MOPW) had been providing contraceptives to Departments of Health (DOH) through Provincial Medical Store Depots (MSDs). As the Government sees it. Additional funds are required for warehousing and data processing. From 1998 onwards. 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.

project PAK/00/P01. 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 main task of technical assistance had been completed and the system had become operational in a few districts. 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. However the policy is silent about the use of money collected from clients. 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. provincial and federal levels for decision making and planning. Most DOH service delivery facilities could not get the re-supply as they did not have system for colleting sales proceeds. However. 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.14-APR-03 . DOH would also charge for the contraceptives from clients but deposition of sales proceed is no more required to get the re-supply. Due to frequent turnover of district managers of the National Programme. On the other hand. According to the supply system introduced in July 2002. Monitoring visits also reveal that there is overstating of performance particularly with respect to IUDs and this is resulting in wastage of contraceptives. lack analysis. The MOPW. 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. Instead of improving the performance by setting targets and charging price on contraceptives. the Ministry of Health received technical and financial support from USAID to design and implement a computer-based HMIS. Overall performance is measured in terms of CYPs produced by individual outlets and service providers. As a result of this policy District Health Officers. f) Health Management Information Systems (HMIS) In the late 1980s and early 1990s. there is dearth of trained staff in the districts. In 1994 when the USAID withdrew its support to the government. PAGE 62 O F 95 . To avoid further interruptions the National Programme (MOH) should have a consistent and reliable supply of contraceptives. frequent transfers of trained staff. GOP funds from SAP-II and DFID grants. Since referrals for contraceptive services are an important aspect of LHWs role and to offer wide range of choices to the clients. monitoring should be improved to prevent the wastage of resources. the MOPW extended its pricing policy to include IUD and Injectable. Departments of Population Welfare use “targets” as management tool for measuring the performance of service providers. 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. In mid-2000. resources should be allocated to procure both injectable and IUDs. The issue related to HMIS is the lack of ownership of the system by the health departments. and non-utilization of the information by district. 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. Data on consumption and stock balances of contraceptives of the LHWs is not consistent and whatever data that exists. in order to receive new supplies were required to deposit sale proceeds into the GOP bank accounts. quality of the information generated.

existing information does not support any significant contribution to either of the three reasons stated above.14-APR-03 . Assistance to these large industrial organizations was channeled through the Directorate of Workers Education of the Ministry of Labour and Manpower. B . Technical Assistance for these activities was provided by ILO. Steel Mills. On the other extreme are the small clinics and health centers run by general practitioners trained in basic medical care. the system collects information on the services provided by the LHWs including information on the community served by the LHWs. However. The focus of earlier UNFPA support was on improving the knowledge of workers related Family Planning and the adoption of a small family norms. the data from the LHWs MIS is more reliable because of the monitoring and supervision system of the National Programme. 2. Airline and Agricultural Development Bank. PAGE 63 O F 95 . (Source .NIPS Assessment). 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.g. This system was further developed with the assistance of UNFPA between 1994 and 1998 through the provision of computer equipment and training. comprising inadequately trained or untrained providers (generally referred to as ‘quacks’) also exists. UNFPA through its Sixth Country Program has provided additional inputs and technical assistance including a mapping initiative for the MOH and MOPW facilities. 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. WAPDA.The National Programme for FP/PHC established an MIS for the Lady Health Workers in 1994. PRIVATE HEALTH CARE Pakistan’s private health care delivery system. Large for-profit commercial hospitals located in big cities provide high quality care to those who can afford their services. UNFPA as part of its sixth country programme is providing support towards development of a common system for the MOH. The institutions comprised 14 major public sector organizations employing a workforce of one million e. The LHW-HMIS is a parallel system and is not a part of the HMIS. Fauji Foundation. typically serving the poorer segments of population. is just beginning to participate in the efforts to improve the reproductive health status in the country. 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. The quality of care and scope of health services provided by the private sector vary greatly between urban and rural areas. A total 450 health service outlets were involved in delivery of Family Planning services for their employees. While no systematic evaluation of past experiences with the TGIs was conducted. Recently. Pakistan Telecommunication & Postal Services. The Armed Forces of Pakistan. However. those inputs were limited to the central warehouse in Karachi and the federal administration in Islamabad. Pakistan Intl. PRIVATE SECTOR 1. accounting for about 60 percent of the total health expenditures. A large informal sector.

Two social marketing firms. 300 maternity centers and 8 teaching hospitals. doctor and LHV. Social Marketing Pakistan and Key Social Marketing. NGO/FOR NON PROFIT Apart from this governmental infrastructure. However. a number of prominent NGOs maintain permanent clinics and operate community-based contraceptive distribution programs. (iii) availability of products to enhance choice and meet urgent unmet need of contraceptives. there is need for developing linkages among these isolated efforts. 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. and (4) change attitudes for paying for family planning services.more widely known as Green Star Social Marketing (GSM) .59 Hakeems and homoeopaths have also been involved in the population program since the early 1980s. 60 3. community mobilization. i) establishment of skilled manpower for delivery of quality service. 4. Hakeems and Homoeopaths. Social Marketing Pakistan (SMP) .000 of them are providing contraceptives and counseling. which provide family planning and reproductive services. There are about 520 small to medium general hospitals. and about 13. This initiative generally known as Social Marketing of Contraceptives is an attempt to use marketing techniques and commercial distribution network to mange. 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. health education and communication and preventive and curative RH services. HRD.14-APR-03 .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. homeopaths and RH. distribute and sell the contraceptive products. dispensers and TBAs. The social marketing projects focus on four goals. and continued 58 Situational analysis of health sector in Paki stan (1995) MOH PIHS survey 2001/02 Hakim.For profit private sector also consists of Registered Medical Practitioner (RMP). (ii) expansion of coverage of family planning services. have been working in Pakistan. especially in urban areas. traditional healers. 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 women’s rights.is the result of a partnership between donors initiated by USAID. 59 60 PAGE 64 O F 95 . population council 2001. 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.

However. sector has grown much faster than the not for profit sector and mainly without any support from the government. A significant number of public sector medical care providers double as private practitioners in the evening. 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.61 However. it is also empowered to impose fine and rescind the licence of workers involved in mal-practice. is also not playing its role in regulating the practices of its members. LHV and midwives. Pakistan Medical Association. DFID and Population Services International (Washington D. the largest and most influential professional organization of medical doctors in Pakistan.by KfW. The Pakistan Medical and Dental Council (PMDC) is not a regulatory body and its role is mostly limited to registering medical graduates. especially for-profit.100 paramedics. It is the second largest provider of family planning and RH services in Pakistan after the Government. ISSUES a) Regulatory issues There are no explicit or effective regulatory mechanisms or laws governing the provision of health services by the private sector. Apart from registration of the above category of workers.400 doctors. A proposal for Ombudsman was conceived but still it is on papers only. providing over 20 percent in CYP and distributing over 58 percent of all condoms.14-APR-03 . while one requires a license to establish and run a pharmacy or medical store. 9. 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. the health managers mostly do 61 Pakistan Nursing Council Act. Key Social Marketing (KSM). b) Linkages with public sector Private sector. Lack of data in this area is also one of the reason for not having required regulatory mechanisms in place. 1973 PAGE 65 O F 95 . the extent of implementation of these few regulatory mechanism is also a matter of concern. which raises serious ethical issues and further deteriorates the quality of care in the public hospitals. Neither has there been any comprehensive national study done on the private health facilities and services. 7.C). SMP manages the largest FP/RH operation in the private sector. solely supported by DFID is making its contribution by supporting local manufacturing initiative for pills. Pakistan Nursing Council is the regulatory body for the nurses. At the district level. while GSM sells condoms and oral pills at subsidized prices through an incentive program to thousands of retailers around Pakistan. 5. no such permission is required by a fresh medical graduate to run a private clinic or maternity home. The two social marketing firms maintain a combined network of 12. 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. The other organization. It is interesting to note that. It is common to redirect patients from public hospitals to private clinics.500 retailers.562 chemists and 47.

a majority of small NGOs and CBOs have been raising funds from 62 Report by presidents task force on human development. housing and transport64 as compared to expenses on food.52 monthly in 1978 to Rs. whether for profit or non-profit is considered to be efficient than the government sector for various reasons. 2000 in 1996-7. 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. the government is experimenting the public private partnership concept by handing over few first level care facilities to NGOs.62 Private sector. it is the low socio-economic class which compromises on expenditures on health. 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. under the health sector reform initiative. 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. There is no consistent fee structure or package costs for the interventions undertaken specially among the small to medium clinics and individuals. It is imperative to provide a safety net to this class through improving the quality and availability of services at the public sector facilities.14-APR-03 . Traditionally few NGOs have been successful in accessing financial resources from donors.not have organized links with the private sector service providers. However. 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. pharmacies and quacks. Per capita expenditure on health increased from Rs 3. The linkage between household income and health outcomes is a well known fact. paramedics. jan 2002 IPRSP 2002 Pakistan poverty assessment 2002 National health Policy 1997 Pakistan poverty assessment 2002 63 64 65 66 PAGE 66 O F 95 . in general. Recently. As a result of which they try to seek health care from cheapest sources like traditional healers. However. c) Affordability In mid 1980s it was estimated that 80% of patients visited private provider (77% rural and 86% urban). Considering the current poverty levels of 32%63 in the country. Generally there is relatively more cooperation on ad-hoc basis between the NGOs and the health and population sector of the government. national health survey from 1990-1995 reported a similar share of 81%.15 percent of married women of ages 15-49 in the lowest expenditure quintile have ever used contraceptives. education. For discussion sake we shall limit ourselves to NGO sector here. 160 in 1997-9865 against the average monthly income of around Rs. it is time to harness and strengthen the potential of non-profit private sector in health and population service delivery.

In the context of devolution and decentralization initiative of the government. AN INSUFFICIENT DEMAND FOR SERVICES A . 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. III. For decreasing maternal and infant mortality. are under utilized in Pakistan. Considering the public-private concept of cooperation between the government and private sector. 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. This could only occur if the adult population in communities is made aware of the warning signs of complications of pregnancy. Simultaneously the need to fund the large NGOs like social marketing which have substantial contribution in the reproductive health sector should not be ignored. most of the peripheral health facilities including BHUs. poor health seeking behavior of people is also a contributor in the low demand and utilization of services.000 infants fail to reach their first birthday ( PRHFPS 2000-01). men are not fully aware of their role in the management of emergency obstetric care. While decision making about availing healthcare facilities is usually the prerogative of the males. should include intensive IEC and advocacy campaigns for men besides effective awareness programs for women and families. Maternal and infant mortality is unacceptably high in Pakistan and continues to pose challenges for public health professionals and planners. Interventions in safe motherhood.000 women die due to pregnancy related cause and about 360.14-APR-03 . LACK OF AWARENESS WITHIN THE COMMUNITY As has been pointed out earlier.their own sources. RHCs and FWCs. correct use of family planning methods. Whereas the awareness about maternal and child healthcare and family planning is low in rural areas. CBOs and other non-profit organizations. They are only called when the matters get out of control of the supervising Dai. STIs and STDs is low in Pakistan. Male members are generally not involved at the time of the delivery as females take care of the whole process. the facilities of the public sector are underutilized for various reasons including availability. Various surveys suggest that awareness about issues such as maternal and child health. perhaps the way forward is enhanced cooperation between the government and social marketing. providing services and organization have not been very successful leaving the small NGOs to fend for themselves. AN UNDERUTILIZED PUBLIC SECTORS As mentioned earlier. PAGE 67 O F 95 . Besides many reasons revolving around quality of care. the knowledge about danger signs of pregnancies and emergency obstetric care is also not very high even in urban areas. the foremost imperative action is referral for seeking essential obstetric care and neonatal services from the appropriate place. child birth and reproductive health issues. to shift the women to a hospital. therefore. affordability and quality of services. B . gender. communicable disease. accessibility. 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. The large umbrella organizations which are mandated to build the capacity of small NGOs in accessing fund.

rural communities. thus increasing the risks of intra. C . health education campaigns have started to focus on safe motherhood. fears of side effects and contraindications. Most of the reasons for this very high unmet need revolve around the information gap. no credible data is available on the overall awareness level about Sexually Transmitted Diseases. lack of specific information. 42 % ever married women had ever heard about AIDS.and pos-natal care) and very high prevalence of delivery at home with the support of a local Dai or family members. SOCIAL AND CULTURAL FACTORS 1. The strategy is in the implementation phase.Awareness about sexually transmitted diseases is also low in Pakistan. PRHFPS has also recorded a rising proportion of women dropping out of contraceptive use due to a number of reasons. There has been an increase in awareness level about HIV/AIDS which was recorded about 75% (Evaluation of NACP-2000). which inter-alia included disinformation. 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. In the public sector. Misperceptions about the side effects of contraceptives are also common. In many cases community members particularly men do PAGE 68 O F 95 .2000-01. daughters or wives and many women often continue to bear children till they are able to produce a male heir. women tend to be considered mostly as mothers. Recently under the umbrella of the Women Health Project. (b) focused IEC on unmet need for family planning. Literacy among women is low as compared to men while malnutrition amongst women is higher when compared with men. This is responsible for multiple pregnancies. most of the couples lack information about the correct use of contraceptives. (c) and advocacy for population issues with decision makers. MoH. male involvement and youth. MoPW). planners and opinion leaders. 33 percent of all married women in reproductive age are not using family planning despite a desire of limiting/ spacing the number of births.and immediate post-partum complications and maternal death. The traditional cultural values of Pakistan are important determining factors. According to PRHFPS. however. However.14-APR-03 . 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. Ministry of Health’s communication initiatives have remained focused on child health and family planning. Awareness about family planning methods is reported to be as high as 96 %. sisters. does not have a national communication strategy to create awareness about health issues and bring about behavior change among people for positive health practices. Women and girls within the poorest and marginalized households bear a disproportionately high share of the burden of poverty. Cultural factors limiting women’s mobility and the lack of proper information contribute to low attendance of health services (ante. GENDER The available social indicators reveal gender imbalances in the society. pointing to the need for urgent attention to improve communication besides improving access to services ( Communication and Advocacy Strategy. However. This is compounded by absence of effective and accessible source of receiving much needed information. According to PRHFPS-2000-01.

With the support of UNFPA the government is in the process of making a GMIS Gender Management Information System. violence against women and economic empowerment. Despite significant steps undertaken by the Government. The above steps taken at various levels within the Government manifest a desire to address gender issues at the community and national level. 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. married or unmarried). 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. Studies are however. which require active male participation and initiative. education. This phenomenon is the result of ignorance. Unpublished data from small qualitative studies suggest that husbands are concerned about their wives’ health. ILO Conventions on the employement of women. and recognize the potential threat to life that a pregnancy or delivery can impose. especially when it came to the care of sick children. It is PAGE 69 O F 95 . the ICPD programme of action. Pakistani men do recognize that they have a stake in the health and well-being of the family. and the Beijing declaration.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. This SAAAW will provide the community perception as well as the incidence and prevalence of violence cases at a national level. A Social Audit on Abuse Against Women (SAAAW) has also been launched with the support of UNDP. which will ensure provision of gender. little emphasis is put upon the needs of men (younger or older. 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. In the year 1987. 2. A code for gender justice has been put up to the cabinet for approval to check sexual harassment in the government offices. About 13% is the use condoms. 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. It was reconstituted as a permanent body in 2000. lack of education of both men and women. the National Commission on the Status of Women was set up. Men’s own reproductive health is also a neglected aspect of health policy and planning in Pakistan. rhythm or withdrawal methods. their knowledge and understanding of obstetric danger signs and the need for referral of obstetric emergencies are incomplete and should be explored. The MoWD has also started a Family Protection Program to provide shelter support and rehabilitation to the victims of violence. disaggregated data on four key sectors of health. A study in Karachi found that men took active part in childcare. 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. Contrary to popular belief in the development circles. MoWD has taken steps to prevent gender discrimination.14-APR-03 . While explicit and elaborate interventions for improving maternal and child health are designed. However. The Government’s commitment to the empowerment of women at the international level includes the ratification of the CEDAW. The role of husbands in other reproductive health issues and decision-making has yet to be studied. should be further documented in order to be addressed adequately. domestic violence continues to be reported.

Operations research is also required on how to train and motivate lady health workers for couple counseling. Worldwide. The Asia Foundation and Marie Stopes Society have developed information. Further research is required to establish the most cost-effective methods for involving men in women’s health interventions. they also play a role in determining the dietary habits of pregnant and lactating wives as well as their young or adolescent daughters. Men as Clients of the Population Welfare Program: Men need advice. National Population Welfare Program included male (FWAs) to cater to the information needs of the male population of their communities. The ‘continued motivation system’ introduced in the earlier days of the Population Welfare Program in Pakistan depended significantly on male motivators.14-APR-03 . and their active involvement in safe motherhood interventions. In Pakistan. several studies have shown that involving men in the family planning programs has a positive impact on contraceptive use. Several studies are available that document increased effectiveness of family planning programs when men are included in the interventions. Since husbands are key decision-makers when it comes to seeking medical care for obstetric complications. Nigeria and India have found that husbands’ knowledge of obstetric danger signs. sexually transmitted infections and cancers of the male reproductive tract. there are large gaps in our knowledge of the prevalence and determinants of men’s reproductive illnesses. there is a need to address each of the three aspects of the reproductive health issues related with men. The focus on men’s involvement in reproductive health is most marked in family planning. leading NGOs including Family Planning Association of Pakistan. educating them about the dangers of these complications could greatly facilitate women’s timely transfer to a hospital in emergencies. no empirical evidence is available of their effectiveness in motivating men about family planning methods. place of delivery and seeking medical care in obstetric emergencies. As husbands and fathers. Research studies in Bolivia. as follows: n Men as Clients of the Health Care Delivery System: Men have their own reproductive health needs. and counseling regarding the all-too-common problems like erectile dysfunction syndrome. and understanding is also lacking on why an overwhelming majority of men visit informal health care providers for sexual and psychosocial disorders. n n PAGE 70 O F 95 . Additionally. particularly prenatal care. are associated with high utilization of obstetric care services by women. Research in these areas would guide policymakers in developing effective strategies to address men’s reproductive health needs. These materials have been successfully tested in varied urban and rural settings. supplies and follow-up services just as women do. choice of birth attendant. However. 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. including sexual education before marriage. fake herbalists and quacks in the urban and rural areas of Pakistan. education and counseling materials on family planning and safe motherhood that are exclusively designed for use by husbands. In summary.the men seeking advice and treatment for their sexual and psychological problems who contribute in large part to the booming businesses of faith healers. Men as Decision-makers: Husbands play an important role in decision-making with regard to obtaining health care for women.

National Rural Support Program ( NRSP). Sarhad Rural Support Program ( SRSC). Punjab Rural Support Program ( PRSP). The initiatives for community participation in the public sector are discussed earlier under the offer of services in the public sector. Huge gaps exist in our knowledge and understanding of men’s reproductive health needs and behaviour. address their needs. Health and District Population Welfare Officers is not ensured. through participation in the planning and management of services to be provided. The present devolution initiative provides a favorable environment for community participation through elected councilors and district Nazims. where the community has the authority to determine what is provided and how. concerned communities should be in a position to own and operate the government’s health and family planning facilities. Centralized management of health programs. Communication involvement means that communities are able to organize themselves. 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). while the government departments also lack mechanisms for quality assurance and consumer satisfaction. and their role in the promotion and persistence of existing child-bearing and child-rearing practices. It may simply mean the community’s compliance with requirements determined by the formal health system. 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. or on collaboration. The (ii) (ii) (iii) PAGE 71 O F 95 . D. Community involvement may also take the form of control. their part in decision-making to seek obstetric care for their wives. Both managers and field workers also lack skills in effective community mobilization techniques. This however. It may focus on contribution. Balochistan Rural Support Program ( BRSP). especially after the new political governments are in place in the Centre and in the Provinces. However.14-APR-03 . is not the case with Pakistan where the public sector facilities are run with little community involvement. it is not clear how the structural changes will develop over the coming years. There is hardly any mechanism for community input in program planning. COMMUNITY PARTICIPATION At the center of the health systems stands community involvement/participation without which services will not reach their full potential. Community participation and networking despite being part of the job description of Executive District Officers. There is little coordination between public sector health organizations and various NGOs working with different communities throughout the country on social and development issues. Ideally. The major issues pertaining to community participation in the planning and management of health and FP services include the following: (i) The government’s 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. THE POTENTIAL ROLE OF CIVIL SOCIETY 1. particularly in the form of payment for services.It may be concluded that the status of male involvement in reproductive health in Pakistan is far from satisfactory. Community involvement in health takes many forms.

lack knowledge and skills in the planning and management of social services in the public sector. education and population. 2. National Reconstruction Bureau. serving on the district and union councils. There are several prerequisites for the success of the devolution process . diffusion of the power authority nexus and distribution of resources to the district level. A) Political Leadership: Under the devolution plan. horizontal relationship with other local departments and external relationship with communities and organizations they serve. user friendly rules and procedures. use information for improved decision. Government of Pakistan. The devolution plan has major implications for all the social sectors including health. PAGE 72 O F 95 . However. The district is the basic administrative unit in Pakistan. efficient and equitable. 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. 2001.clear redistribution of provincial and district authority and responsibilities. capacity development of the district managers. for effective delivery of services.14-APR-03 . 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. provide supportive supervision. decentralization of administrative authority. Chief Executive Secretariat. and ensuring community participation for better utilization of social sector services. the performance of district managers is limited by their capacity to prepare district plans. The proposed plan was based on five fundamentals:67 devolution of political power. a problem area is that the newly-elected local representatives. transfer and posting. (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.devolution plan makes the line departments responsible to and accountable directly to the communities they serve. 67 Local Government Plan 2000. sensitization of the local political leaders about the importance of social sector concerns. 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. and a paradigm shift in the minds of the government functionaries to be accountable to the communities 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. and effectively function as a coherent management team. suppression of administrative malaise in timely recruitment. This would foster for a district strategy enabling the managers to decentralize authority and responsibility together. enhance funding and their timely utilization and effective monitoring and supervision system to ensure availability of quality services and material. August 2000. de-concentration of management functions. The districts are uniquely placed at the level where they are in a position to maintain a vertical relationship with higher management levels. involve communities. 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.

This initiative would imply a shift of responsibility for social services. the devolution initiative is potentially the most important organization and management reform to come around in many years.14-APR-03 .b) Devolution and its Implications on District Health Services For the social sectors. 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. from the provincial governments to the newly created district governments. PAGE 73 O F 95 .

which has the responsibility of population planning. the projects/programmes become part of the GoP’s macro development plan. PUBLIC SECTOR’S PLANNING. The experience has been that there are often long delays in release of funds. This situation also has unfavourable implications on staff recruitment and development. and (b) Planning Division/Planning Commission at the federal level. (e) Executive Committee of National Economic Council (ECNEC). which is termed ‘Recurrent Budget’ or ‘Non-Development Budget’. Except for a small proportion of the overall expenditure. BUDGETING AND FINANCING STRUCTURE AND ITS RELATIONSHIP WITH THE POPULATION PROGRAMME The Ministry of Population Welfare. (d) the Economic Coordination Committee of the Cabinet (ECC). INTRODUCTION The planning process of the Government of P akistan (GoP) starts with the development of various short and long-term plans. which consists involving the (a) Planning & Development Departments in the provinces. and discourages recruitment of well-qualified professionals. The concerned ministries and departments take part in the planning process by preparing a ‘PC-1’ for each proposed project/programme. The GoP has established a hierarchy of stages for the development and review of plans. After approval. 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. pertaining to the regular federal infrastructure. (c) the Central Development Working Party (CDWP). 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. Failure to integrate population staff into the regular services further limits opportunities to build cadre commitment towards population goals within the civil service. in which the justification for and expected benefits of the components and anticipated costs (the planning budget) is given in a specific format. Funds for the approved projects are allocated in the Government’s Annual Development Programme (ADP) and the project becomes part of the Public Sector Development Programme (PSDP). has been funded since its inception through the ADP. the whole programme is part of the PSDP and has constantly faced the danger of being reduced during the periods of serious financial crunches.CHAPTER 4 MOBILIZATION OF FINANCIAL RESOURCES FOR POPULATION AND REPRODUCTIVE HEALTH PROGRAMMES I. PAGE 74 O F 95 . which occur when the liquidity position of the government is not favourable. These include (a) the Departmental Development Working party (DDWP).14-APR-03 . there is another budget in the public sector. 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. and (f) National Economic Council (NEC). II. 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. (b) Provincial Development Working Parties. especially at the provincial level. In addition to the ADP.

2% against the overall public sector expenditure from both development and non-development budget. 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.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. One of the major reasons for little progress in the social sector has been the low level of resource allocation.8 billion) during the last decade (financial years 1990-91 to 1999-2000). This rose to 19% in 1998-99. has increased from 0. The increase between 1996-97 and 1997-98 was 6% only. Field activities too have been transferred to the provinces under an Ordinance issued in 2000.In line with the Government policy of decentralization and devolution. The figure in Table 4. and other years when it fell to less than even half. 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. Throughout this period there had been a regular trend of increase in the overall public expenditure.27 percent.552 in 1998. The current Human Development Index (HDI) for Pakistan. The transferred employees of the Population Welfare Programme have become provincial civil servants under full administrative control of the provinces. on the average it was around 5. This situation indicates that the expenditure on social sectors has not increased in proportion with the general increase in public expenditure.14-APR-03 .343 in 1975 to 0. 6. but dropped drastically to 0. Pakistan’s progress in the social sector has been unimpressive. 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 1996-97.04% in 1999-2000. PAGE 75 O F 95 . 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. but thereafter the trend became erratic. III. Further. Social development in Pakistan has been subject to various constraining factors. of which some are generic while others are sectoral.1 compares social sector expenditures with the overall public expenditures (Rs.655. It shows that the ratio of social sector expenditure remained only at 8. as it did in 1992/3 when it was a mere 2. Despite an overall impressive economic growth record.

Funds being insufficient in the first instance are irrationally used more on brick and mortar and salary rather than on service delivery and quality. 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. April 2001. Exp. 200 0 Source: ADB.1995. imprecise job descriptions and inadequate training plans for human resource development.1994. Public exp.199991 92 93 94 95 96 97 98 99 00 Total Expenses Social Sect.14-APR-03 .1992.1: 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.1998. which is resulting in poor targeting. high costs and poor maintenance. 1990.1991. Interest Domestic Interest Foreign Social Sect. RESOURCE ALLOCATIONS AND EXPENDITURE OF THE POPULATION AND REPRODUCTIVE HEALTH PROGRAMME AND THEIR RELATIONSHIP WITH THE POLICY RECOMMENDATIONS Resource Allocation & Expenditure PAGE 76 O F 95 . As % of total exp. Exp.1993. 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. Dev. • • IV. Non-observance of the policy of merit and transparency in recruitment.1997. Some of the factors responsible for this inequity are as follows: • • Failure to involve the local community in project design and implementation. Public Exp. Highly centralized administrative and financial systems which are resulting in resource leakage.Figure 4. 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.1996. Draft Poverty Assessment for Pakistan.

Until the 7th Five-year Plan. Reproductive Health Project-Pakistan.039 5.9 86.300 3.14-APR-03 . However the change has been quite gradual.100 15. public expenditure on the population welfare programme in Pakistan had initially been extremely modest.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. The increase in allocations continued in the current 9th Five-year Plan.184 3. 2000.800 824 9 617.039 7.340 1.01 percent of the overall macro plan size. and it fluctuated in response to the variations in programme strategies and in political commitment. were incorporated to provide a more comprehensive Reproductive Health Services Package. Datalines.535 9.2 shows that except for the initial three Plans.3.8 74 6th (1983-88) 7th (1988-93) 8th (1993-98) 9th (1998-03) * Upto November 2002.654 *10.2 82. allocations remained between the range of 0.1 *66. in which the allocation increased by more than 157% over preceding plan allocations.9 81.686 3. in the later y ears. Table 4.625 2. As can be seen in 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. Table-4. 45. The expenditure trend (Table 4.0 (1970-78) 5th (1978-83) 1. As explained in Chapter 3. other elements of reproductive health. as defined in the ICPD Program of Action. in million) % of Actual Plan ADP Actual % of ADP to Exp.0 84. 2. Options. 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. especially in the current 9th Five-Year Plan.029 834 103.The population programme of Pakistan is predominantly funded by the GoP and international assistance.933 88.3 *67 Source: ADB TA-3387.08 to 1. A noticeable change was observed in the Eighth Plan.914 *6. when the allocation for population programme was substantially low.2: Ministry of Population Welfare Allocations and Expenditure (Rs. Policy Recommendations Following the ICPD there was a change in the Government’s approach to the country’s reproductive health issues in the light of inherent socio-cultural issues that affect fertility.5 100 77. the overall implementation of the social-sector related programmes remained weak and allocated resources could not be fully utilized. PAGE 77 O F 95 . thereafter while there were relative increases in the social sectors.

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. and family planning Source: World Bank. tetanus toxoid vaccination.9 2. as an integral part of total health expenditures.000 million) Expenditure/Allocation 64. 1.1% 100% DHQ 3.14-APR-03 .8 62.8 22.8 7.1% 4.200.8% 5.7 Expenditure on reproductive health.2 31. 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.181.3 1.2 2 2 2.4 1.920.4: Cost Share of Preventive & Curative Services by Type of Facility BHU EPI MCh* Total Preventive Total Curative Total Facility Cost 25.6% 15.2 1.172.2 1.4 19 17 4.9 2.2 11.3% 2.7 Training 8 9.1 38.0% 17.1 23.8 15 14.1 36.4: Table 4. growth monitoring.4 82. 1998.6 (Rs.2 Research 2. Pakistan: Towards a Health Sector Strategy The Netherlands Interdisciplinary Demographic Institute (NIDI).17 70 (%) Source: Ministry of Population Welfare 1999-00 15.6 1.100 1.1% 57.4 1.5 1.7 0.6 0 2.2 44.8% 100% *Includes antenatal care.4 1.1 11 Construction 2.3 6.6 0. A World Bank study attempted to give a break down of the total cost of various health facilities.5 98.000 1.144.8 Services IEC Programme 11. is not being reported separately.256.433 2.133 1.6% 7.3 21.401.4 5.3: 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 26.8 3.6% 100% THQ 5.4 Logistics and Supplies 2.8 46.9% 100% RHC 9.194. Brief details are reproduced in Table 4.7 1.million) Total Allocation (Rs.6 94.4 62.4% 84. under the UNFPA’s Resource Flows for Population Project. PAGE 78 O F 95 .9 22.7 4.2% 95.9 5 5.9 Organisation Population Welfare 46.Table 4.1% 1. funding from international resources increased by about 18% in fiscal 1998-99 over the ratio in the fiscal year 1997-98.8 20.9% 92. However.7 1 Total Expenditure 710.3 55. has been collecting data about Pakistan’s resource flows to its population sector for the last few years.2 1.1% 42.4 16.9 1.3 45.

5% 7.1% 51.6 indicates that assistance in this sector from the PAGE 79 O F 95 . At the end of 2002.5% 0. Table-4.The Government of Pakistan’s 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. the country paid $1.7% 0.3% 26.13% 0. one of the limiting factors is the resource crunch.1% 23.1% V.5 23% 77% Percentage Going To: Ministry of Population Welfare Ministry of Health Ministry of Women Dev. Population planning is an important component of the social sector that is very closely related with poverty.887. is faced with widespread poverty.3% 1998-99 3.6% 279 92. the external debt burden was US$36. [See Chapter 1. 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.934 28% 72% 1999-00 4.7% 76.2% 49. Pakistan.4% 23. Pakistan cannot be expected to meet its essential targets without the availability of external financial assistance.8% of its overall foreign exchange earnings. Ministry of Education Ministry of Labor & Manpower Provincial Health Departments Total Budget NGOs From international Resources From Self generated Income 50% 22.2% 24.6% 546 82.5% 0. A review of the Table 4.247 26% 74% 3.3% 0.1% 0.8% 0.7% 0.9% 8.5 billion.998.8% 26.8% 4.6% 50.] For undertaking the plans that focus on poverty alleviation. In the fiscal year 2000-2001.14-APR-03 . which is 13.4% 17. as with many other developing countries.5% 22% 529 91. Given this situation.01% 0.5 23.5: 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 3.6% 216 95.3% 0.96 billion in debt servicing. THE ROLE OF EXTERNAL ASSISTANCE IN FINANCING THE POPULATION AND REPRODUCTIVE HEALTH PROGRAMME.24% 26.

the Asian Development Bank. PAGE 80 O F 95 .519 14. World Bank/IDA.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. Note that the NGO share actually reflects additional donor resources as most NGOs are donor dependent. the main international donors for population activities were UNFPA. By the year 2000. As can be seen from Table 4. except for the year 1994 when the bilateral funding was only 37%. USA. as well as programmes that address the collection and analysis of population data. donor funding for population activities in Pakistan has fluctuated.092 18. Financial Resource Flows for Population Activities in 1999.967 28. SAP-II.771 15. the costs of the implementation of reproductive health programmes.561 28.028 12.761 33.14-APR-03 . Table-4.international community continued at a reasonable level during the last decade despite an adverse political climate. will cost $17 billion by the year 2000.6.508 15. Approximately two-thirds of the projected costs in developing countries will have to come from the international donor community. and there is an increasing flow of resources in the form of international assistance for population activities. Bilateral assistance has been the main channel. The international donor community has shown its commitment to achieve the goals and objectives of the conference.670 15.6: Donor funds for population Year Total $ in 000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 15. UNFPA is among the main donors for Pakistan’s population sector. New York. The 1994 ICPD’s Programme of Action estimated that in the developing countries and the countries with economies in transition. including those related to family planning. maternal health and the prevention of sexually-transmitted diseases.

Islamabad (1994-2002) in US$ Total Expenditure 3.000 3.000 1995 5.000 1997 5. a majority at the district level. The role of national NGOs in Pakistan has remained limited due to several reasons including those related to national security.86 reveals that most of the time 85% to 90% funding has come from international donors.111 VI.000 1996 6. The absorptive capacity of local NGOs is relatively low and constrained by the overall lack of funds. the NGO sector was almost non-existent at the time of independence. (See Chapter 3).889 Total estimated 57. Save the Children (US). The All Pakistan Women Association (APWA) was t e first organisation and was founded in 1949.500.788.000 6.888.111.000 4. around 16.000 600. The Asia Foundation.14-APR-03 .000. A glance through Table 4.889 Source: UNFPA-Pakistan.000 3.000. According to an estimate. the Marie Stopes Society (MSS) and the Family Planning Association of Pakistan.200.7: UNFPA Expenditure Trend Year Program Regular 1994 4.000. It also envisages the PAGE 81 O F 95 .000 1998 5. NGOS’ AND PRIVATE SECTOR’S ROLE IN FINANCING OF POPULATION AND REPRODUCTIVE HEALTH ACTIVITIES In Pakistan.000 4. The political environment in Pakistan is not congenial for local NGOs. THE FINANCIAL RESOURCE GAP OF PAKISTAN’S 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.000 2001 7. VII. Few examples are the Pakistan Association for Voluntary Health and Nutrition Activities (PAVHNA).000 2002 7.711.000.111 37.000.000 2.500. Some of these NGOs have. and (b) national NGOs.000 NGOs are currently working in Pakistan.000.000.400. and the Population Council. by taking a lead role in coordinating the implementation of a multisectoral programme. Most of these NGOs implement their own social sector/population programmes for which funding is largely by international donors.400. Some of the international NGOs are the Pakistani affiliates of their international offices like Marie Stopes Society. They tend to be dependent on funding from international sources. however.600.000 1999 5.100. Two types of NGOs are active in Pakistan: (a) international NGOs .000 4.000 2000 7.000.600.000 Average 94-02 5. have shown their potential to work in difficult sociopolitical conditions with a measure of success in achieving their objectives.600. The h number of NGOs has steadily grown over time and rapidly expanded during the last two decades.000 4.Table 4. Efforts were made in the past to organise local NGOs for increasing their role in the social sector but there have been constraints.

timely availability of contraceptives for all contraceptive and RH delivery outlets.761 Source: Planning Commission. elected representatives.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. EXPENDITURE ON PAKISTAN’S POPULATION PLANNING PROGRAMME IN P R E . The ICPD emphasized the importance of education for women and girls and the need to decrease maternal mortality. 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). The total financial outlay for the Plan period has been proposed at Rs. 39 billion. Government of Pakistan VIII.ICPD PERIOD.941 10671 14510 6638 4793 2568 39. human resource development and advocacy.monitoring and devising of an appropriately consolidated reporting system by partnering with NGOs.14-APR-03 . AND A COMPARISON WITH COUNTRIES IN THE SOUTH ASIA REGION. Those governments which ratified the ICPD-POA agreed to increase their annual spending on population and health-related programmes. 72 billion against which the PSDP commitments by the Government are estimated at Rs. focusing on reaching and expanding services in rural areas.180 (Rs in million) Resource Gap 14413 10176 4875 2398 899 32. The breakdown of the Plan budget and resource gap is given below: Table 4. 33 billion which needs to be met through external assistance. and increased expenditure on research. PAGE 82 O F 95 . The goal of the Perspective Plan is to achieve replacement level fertility by the year 2020 through a restructured population programme. increasing investment from the private sector. 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. academia and media.AND POST. This leaves a resource gap of Rs.

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 15.6 89. and funding under the Social Action Programme.3 93. implementation.• • • • • Incorporation of major elements regarding social sector planning. PAGE 83 O F 95 .14-APR-03 .2 3.6 1.0 12.6 45.8 Source: UNFPA.1 57.1 74.1 1. 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. Establishment of a clear policy of shared inter-ministerial responsibility for implementation of population sector plans.9 33.6 28. their policies impacted significantly and positively on resource flows for population activities in the immediate post-ICPD period. Financial Resource Flows for Population Activities in1999.6 58.5 16.7 1.1 1.4 87.6 39.4 60. Table 4.0 28.8 33.1 18. While the allocations of the international donor community funds encouraged a commitment of signatory countries to achieve ICPD objectives.2 14. Producing working definitions of reproductive health in both the Health and Population Welfare ministries.7 2.2 44.6 100.8 3.6 31. Table 4.9 2.8 2. and Promulgation of a national plan of action for the empowerment of women.6 75. their domestic policy objectives have now changed substantially.7 1.10 above.8 15.5 0. with ongoing efforts to forge common definitions.9 1.2 3.1 87.8 65.9 21.0 2. 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.3 2.0 4.1 2.6 2.9 25. 1999.

IX.14-APR-03 . 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. PAGE 84 O F 95 . 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 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. byelaws. Concurrently it poses new risks and challenges also. systems and procedures are framed so that various components of the devolved set up could function smoothly and deliver efficiently. and it is necessary that proper rules of business.

On the other side. OVERVIEW Chapters 1-4 confirm the relevance and vitality of population and reproductive health issues to development in Pakistan. it could look at improving the offer or supply of services. a high number of maternal deaths inconsistent availability of quality of care services and supplies. Reductions in total fertility rates and population growth underline this. This lends PAGE 85 O F 95 . The policy commitment to population and reproductive health issues is strong.CHAPTER 5: RECOMMENDATIONS FOR STRATEGIC ACTIONS IN POPULATION.14-APR-03 . despite much progress. particularly family planning is high. are still considerable. Public awareness on reproductive health issues. a low national resource base for the social sector. There is a solid physical health and population welfare infrastructure with impressive national coverage. services inadequate to young people. a broad coalition of key government institutions. But the road this way has been long and tough. On this side. Thirdly. the balance sheet is a fertility transition in the making. still relatively low contraceptive prevalence. a combination of information and communication. the balance sheet reveals several and multi-faceted features that lend a greyer shade to this picture begun above. reliable NGOs. II. CHILD SPACING – A NATIONAL CAUSE § The much heralded fertility transition in Pakistan is real. Strengthened supervision of service delivery points could hold a key function in enabling this process. The stage would thus seem to be set for significant progress on such issues as fertility reduction and maternal health. enhanced management and technical capacity at all levels of service delivery (federal. social mobilization and enhanced counseling skills could entice better awareness and demand for quality services through better-informed choice. Secondly. There we find high unmet demand for family planning. Any package aiming to address this array of concerns and requirements could begin by contemplating a four-pronged approach: § § § First. giving rise to the hope that mistakes committed elsewhere will be avoided in this country. To make this possible. community organizations. Significant achievements on the one hand are softened by formidable tasks still ahead on the other. stretch to the limit the capacity of responsible government institutions to deliver on their mandate. provincial and district) could strengthen service availability and quality of care delivered. An open and pro-active approach to the threatening HIV/AIDS epidemic sets Pakistan apart from other countries. including population welfare and health. urban/rural). and service delivery points with insufficient numbers of qualified staff. A systematic advocacy initiative for a common vision and strategy towards a substantive partnership for change is called for. REPRODUCTIVE HEALTH AND GENDER I. Because of financial and security constraints. and the private corporate sector with clearly defined roles and responsibilities recommends itself. Educational disparities (girls/boys.

Such a policy could at its core rest upon a structured and mutually supportive partnership of public and NGO sector. These efforts have been effective as is evident from findings of various household surveys. A . 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. a 5 comprehensive youth and adolescent health/reproductive health policy is urgently required. In view of the social cultural and religious constraints this is no mean achievement. there is a need to bridge some gaps and orchestrate its implementation. 2. 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. Considering that people under 2 years of age constitute 63% per cent of the population. people have been made aware of family planning choices through field workers. Awareness regarding family planning methods has been consistently rising since 1991 and is almost universal according to PRHFPS 2000-01. However. agenda for health sector reform”. The Human development section of PRSP should look at fertility reduction as a first priority. Adjustments in policies and reorientation of advocacy efforts to safeguard this transition are necessary. These documents elaborated by the Government of Pakistan constitute a remarkable and very comprehensive policy framework for the social sector. the national health policy 2001 entitle “The way forward. PAGE 86 O F 95 . the national plan of action for women. and the national policy on education. the transition could be jeopardized. Similarly. Past IEC campaigns have been relying on mass media for creating awareness and have also focused on increasing visibility of the sources of services. to ensure that investments in other areas are not constantly undermined by an uncontrolled demand. the population policy of Pakistan (July 2002). 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 following suggestions try to address both.14-APR-03 . the Population Welfare Programme has always maintained a communication campaign to support its service delivery efforts. B .uncertainty about the ability to sustain the trend. ADJUSTING EXISTING POLICIES 1. There is evidence to suggest that with growth in contraceptive use tapering off. ACHIEVEMENTS In the public sector. NATIONAL ADVOCACY AND COMMUNICATION STRATEGY 1.

and setting up a road map for achieving the objectives. namely the presence of nation-wide physical service infrastructure. political leaders. and for an effective implementation of programs serving the most in need. for a sustained increase in resources for population and RH. to address the needs of rural and urban poor.14-APR-03 . Advocacy for increased girls’ enrolment is indispensable to the success of any family planning campaign. Nazims. in 1994. community leaders. 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. information. III. education. the National Programme for Family Planning and Primary Health Care is a success story and plans are underway to expand the Program. religious leaders and scholars. This would be achieved though a nationwide advocacy and social mobilization program at all levels involving elected leaders (MNAs. to 150. if fully implemented. ACHIEVEMENTS Pakistan’s health and population welfare service system has a distinct advantage over many other developing countries. Ministry of Health through its National AIDS Control Program has been able to create around 70 % awareness about HIV/AIDS. The relationship of ideal small family norms and years of schooling is universally recognized. 2. Socially and culturally acceptable long-term IEC and advocacy strategies with clear objectives. The strategy. defined target audiences and focused messages should be made part of all population and reproductive health interventions. SERVING BETTER AND REACHING OUT 1. 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. Launched. has the potential to narrow the gap between awareness and practice of family planning. MPAs.000 Lady Health Workers. identifying key target audience. RECOMMENDATIONS Investment in capacity building should be made to allow the Ministry of Population Welfare to become the lead department on policy issues. SERVING AND MANAGING BETTER – THE PATH TO IMPROVED SERVICE DELIVERY A . and monitoring of population aspects and to ensure effective support to the coordinating mechanism mentioned above. male and female councilors). specifically women. which now employs 70.000 fully PAGE 87 O F 95 . Complementary to population and reproductive health issues is girls’ education. advocacy.MoPW’s Communication and Advocacy Strategy 2012 fills the gap of behaviour change communication by defining clear strategic objectives. and members of communities.

. 2. mechanisms for catering to the information needs of men. and capacity and skills enhancement. services should be expanded to include prevention. 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. with appropriate equipment. this is due to several factors e.14-APR-03 . especially in the rural areas may be put in place. and to strong cultural barriers preventing pregnant women to attend health clinics. accessibility. and well maintained amenities for women. They should therefore provide an integrated PHC/RH including FP service package. This will allow the Programme to reach about 85 percent of Pakistan’s rural population. drug range. there is room for improving the quality of these services and for making them more accessible. as well as procurement. and to preserve confidentiality and privacy. Beyond family planning and maternal health services. services. and to respond better to demand. storage and delivery of contraceptives. as described in Chapter 3. and attractive to women. In addition to the LHW programme. training curricula. PAGE 88 O F 95 . to ensure proper attention by staff. equipment. available. and appropriate CEC equipment. and equipment. In view of the findings. Covering women’s needs therefore require at the same time the improvement of facilities. ante. Existing health facilities should also cater to the RH needs of men. and the existence of outreach services. Ministries responsible for PHC services should allocate adequate funding for procurement and distribution of contraceptives.trained Lady Health Workers by mid-2003. and be provided to clients at a minimum fixed price. As mentioned in this document. Both Ministries should harmonize job descriptions. However. The role of FWAs ( male) should be studied for its effectiveness in informing males about reproductive health issues. clean. appropriate staff including a medical officer. This would include inter alia the definition of treatment regimen. Mobile service units should serve isolated communities which have restrained access to health care. standards of quality. men and young people.and post-natal care remain very low. especially in rural and slums areas. detection and treatment of sexually transmitted infections (STIs) including HIV/AIDs. Contraceptive should be procured and distributed through the Central Warehouse. supplies.g ability to pay. and Mobile Service Units (MSUs) organized by Ministry of Population Welfare. this charge being kept by the service provider as an incentive. there are other outreach mechanisms that exist like “camps” deployed by both Health and Population. A “Woman Friendly Initiative” should be launched to guarantee proper. In this connection.

ACHIEVEMENTS To decrease maternal mortality. RECOMMENDATIONS Staffing should comply with minimum standards especially providing for female staff at Primary Health Centres. IEC and counselling materials should be made available at service delivery points. youth centers. the Government has taken critical steps in the area of safe motherhood. and initiatives like the Safe motherhood program in NWFP will have an impact on MMR. water and electricity supply. Delivery rooms should comply with basic standards (e. PAGE 89 O F 95 . staffing. These loans are investments made in addition to those of the LHWs national program. infrastructure has been improved in many districts. educational and recreational facilities in order to improve availability and accessibility. Community midwives with adequate supervision and training should provide ante. and to address gender related issues. Youth and adolescents services should be organized in a broader context e. Routine training of service providers s ould include a module on dealing with cases of domestic h violence. For instance 2 female obstetricians should be posted in each District Headquarters Hospital. Appropriate infrastructure. and the Reproductive Health project (40MUS$) covering 34 districts. and the supervision and training of EmoC staff at Tehsil Headquarters Hospitals. addressing the critical issues of equipment and supply. SAVING MOTHERS 1. Civil society organizations and NGOs working with adolescents should be supported to establish specialized adolescent health centres and telephone help-lines to advise and guide the youngsters. In parallel to these positive developments. and transport. communication. This should be supported by an information campaign to increase awareness about those services. Compliance with these standards should be regularly monitored. counseling. A comprehensive Emergency Obstetric Care (EmoC) program should be implemented nationwide.g. and to advocate special legislation to protect the rights of youth and adolescents. B . 2. and some of the undeserved areas have been staffed. These staff would have the responsibility for outpatients. size.and post-natal care. should be available at Tehsil and District level. and EmoC. including safe basic obstetric care. facilities. the launching of pilot community midwives projects. ventilation. stable room temperature).g.14-APR-03 . referral.Training sessions should be arranged for health and reproductive healthcare providers to adequately respond to the needs of youth and adolescents. staff have been retrained. Currently two loans from the Asian Development Bank are under negotiation: the Women Health project (75MUS$) covering 20 districts.

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. usually the larger ones. Even these often rely on donor assistance.14-APR-03 . Smaller NGOs could benefit from structured support and backstopping through an umbrella body on throng decentralized mechanisms at district level. Advocacy and information of labour unions. The corporate sector (private and public) in Pakistan has a long tradition of providing quality health care services to its workers. PAGE 90 O F 95 . The community mobilization expertise of relevant NGOs should be harnessed for effective utilization of reproductive health services offered by the public sector. schools and mosques established in the housing colonies of large industrial units and lastly a large migrant seasonal workforce associated with several industries. Advocacy for support to RH and family planning should be undertaken with the Board Members of private companies. have the capacity to deliver sustained services. BUILDING ALLIANCES A ND SUPPORTING COMMUNIT I E S ACHIEVEMENTS 1. 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. FAMILY HEALTH FOR HUMAN WEALTH A. labour colonies. enhance counselling skills and that these be supplemented through the provision of visual materials to undertake these tasks.IV. 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. However few. 2. higher management and relevant operational levels with a view to enlisting their political support and commitment for RH/FP in their organizations. RECOMMENDATIONS District officers’ skills in community mobilization should be enhanced in order to ensure effective involvement of all stakeholders in reproductive health initiatives. collective bargaining agents and office bearers should be undertaken to encourage workers to improve their RH status. which as with social marketing. The NGOs constitute a large community. perform an important function in RH service delivery. Referred to as the Target Group Institutions (TGIs) this sector has earlier been part of the MoPW’s efforts to reach out to workers/employees of large enterprises and industrial organizations. The TGIs offer an opportunity that should be further explored.

Currently two reports are in the final stages: District Profiles of Pakistan and AJK. There is a lack of expertise in population in the country. PAGE 91 O F 95 . and Reproductive Health of Youth: Perceptions. KNOWING BETTER A . over the years. and twinning arrangements. surveys and researches has been significant. These studies are widely quoted by the researchers. Among the numerous reports. 1991. several independent consultants have come forward in the RH field. Population Cells in some of the universities where demographic research is carried out. ACHIEVEMENTS Aiming for a better understanding of population and development calls for strengthened capacity in population and RH data collection and dissemination. Pakistan Fertility and Family Planning Survey. 1987. with various international demographic research institutes. should be strengthened personnel-wise with a defined agenda for the inter-censal period. These include Pakistan Institute of Development Economic. ENHANCING NATIONAL EXPERTISE 1. 2001. Pakistan Demographic and Health Survey. 2. Attitude and Practices. NIPS’s contribution in carrying out various studies. PCO is short of trained staff and the existing personnel are not always abreast with the modern data collection and analysis techniques. recognition may also be made of other agencies and persons in the area. The Agha Khan University.14-APR-03 . Such a centre could have exchange of researchers. raising its expertise at international level. and Pakistan Reproductive Health and Family Planning Survey. Of late. Follow up and monitoring of ICPD indicators could build on the valuable experiences of the National Institute of Population Studies (NIPS). has had its professionals trained abroad but has seen attrition too as several of them have left for better opportunities. which is being merged with FBS. NIPS. they have carried out studies and researches after having been commissioned by various international and donor agencies. 2002. 2002 (118 individual reports).V. Creation of an in-country academic centre of excellence for training of population specialists is required. RECOMMENDATIONS The capacity of the National Institute for Population Studies should be further enhanced by training the existing personnel. mention may be made of The State of Pakistan’s Population. At the same time. 1998. though sporadically. Here. Pakistan Census Organization conducts decennial census every ten years with a long slack period in between. and. inducting new on a permanent basis. This organization.

The MoPW in 1987 developed a contraceptive logistics MIS reporting on stock balances and supply statistics. where information on RH and contraceptives can be shared.B . Especially the use of information technology should be institutionalized in the district health management systems for knowledge sharing. Currently. The MOPW and MOH are working towards a common RH information system at the district level. The information from these systems should be used to monitor the RH and contraceptive logistics status at the district levels. 2. the HMIS system is being evaluated for up gradation with the assistance from UNICEF and UNFPA.HMIS and building capacity of the district managers in data analysis and its use for decision making in selected districts. analysis. Both the ministries through the assistance of UNFPA have also initiated the mapping of health. 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). The reporting regularity from facility to district and above should be further strengthened by regular monitoring of the facilities and districts. 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. Currently the system is operational in all the districts. PAGE 92 O F 95 . policy making and monitoring the impact of health and population programs is imperative. The district health and population departments should establish a mechanism for providing regular feedback to the service providers and facilities. This was further strengthened in 1994 and 1998 through UNFPA’s assistance.14-APR-03 . Realizing this. the health management information system (HMIS) was initiated. POPULATION AND RH MONITORING 1. which will also include the development of a common interface between the population MIS and the HMIS at the district level. ACHIEVEMENTS The need for relevant information for planning. The National Programme is piloting integration of facility based HMIS with the LHWs. in the early 1990s. 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. under the recent initiatives by Ministry of Health. population and NGO facilities for a compute based Geographical Information System (GIS) in selected districts. The capacity of the district staff of MOPW and MOH in collection. dissemination and use of information should be enhanced.

The head of district council. PAGE 93 O F 95 . 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. AN IMPORTANT STEP 1. The official hierarchy may be assisted in providing them data on a disaggregated basis which is relevant to the district. It should not only be comprehensive but repeated periodically. called the Nazim will be incharge of all the activities to carry out which 11 groups of departments have been created in each district. DEVOLUTION. Districts find themselves having to plan. To fully involve the communities. Since. Aside from technical skills. B . local councils have been established through elections. management and supervisory skills require strengthening. The main challenge now is that of planning and implementation capacity. the inception of the district governments in mid 2001. 2. supplies and even infrastructure is needed. ACHIEVEMENTS Decentralization holds enormous promise. the provinces are placing funds at the disposal of the district governments. program and implement activities at an unprecedented scale. ENHANCING DISTRICT MANAGEMENT CAPACITY 1. both on the part of the elected representatives and the officials of district hierarchy. Considerable enthusiasm and goodwill should be reinforced through a coherent and extensive capacity building effort. 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. But it also contains significant challenges. ACHIEVEMENTS A very important administrative step of far reaching consequence has been the Devolution Plan. RECOMMENDATIONS An awareness and training programme of the elected representatives at district level is required. Now. Physical capacity in the form of equipment.14-APR-03 . MANAGING BETTER – TOWARDS A RELIABLE SUP PLY AND OPTIMAL USE OF RESOURCES A .VI.

operationalizing MIS and enhancing management capacity. planning.2. RECOMMENDATIONS There should be continued technical support in policy monitoring. Social sector allocations and expenditures at the district level should be enhanced.14-APR-03 . PAGE 94 O F 95 .

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