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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Financial resources allocated to the population and health sectors by the Government have risen. fertility and poverty. Undoubtedly unattended population pressures are likely to contribute to the creation of disastrous social and political environment in the country. Rs.5 billion requirements are estimated for the next 19 years for achieving the fertility replacement.obstacles to using family planning. in seeking care during pregnancy and delivery and in the recognition of symptoms and treatment of RTIs. STIs and AIDs. PAGE 3 O F 95 . 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.49. 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. Pakistan requires support to achieve replacement level fertility by 2020. Furthermore. However as mentioned in the population policy of Pakistan. 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.14-APR-03 .

2001. Govt of Pakistan. NIPS.9% 27.40 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 PRHFPS op.0% 30.7% 33.cit. op.000-80.4% 4.000 lb 77% 19% 51% 28% 1. PRHFPS op.67 5. of Pakistan.6% 39. 2001-2002. 2001 Ibid Ibid Ibid Ibid Ec.000 Year Source 2002 1981-98 2002 1998 1998 1998 1998 1998 2001 2001 2000 2002 2000 2001 2000 2000 2002 2002 Economic Survey.cit. cit. Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid PAGE 4 O F 95 .2002 Pakistan Reproductive Health and Family Planning Survey. Ibid Ibid 1998 Census Report of Pakistan. Govt. PIHS – Round IV.5% 43% 19% 3.7% 21.16% 32.3% 93. 20002001.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. UNICEF PRHFPS op. Estimate.1% 34. Surv. See Chapter 3.69% 2. cit Ibid UNAIDS UNAIDS 95.0% 97.5% 108/100 63 yrs 82/1000 lb 103/1000 lb 300-700/100.77 3.800 70.14-APR-03 . 2002.

In the main text of the document. The source of information is also cited. different figures would be found. 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 . however.A Note on Statistics and Figures Key statistics on population. at places. health and family planning. are given in the Reproductive Health Profile. PAGE 5 O F 95 .

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

............................................................................................................................. A........50 PUBLIC SECTOR.................................................................................................................................................................................................................................................................. Ministry of Health ........................B... OTHERS.................... 71 2.......................41 Contraceptive prevalence .......................................71 1.......................50 Health policy framework........................................................... An insufficient demand for services.....................................................14-APR-03 ..59 d) Quality of services....................................... 65 a) Regulatory issues ........................................... PAGE 7 O F 95 .............................................. B.........................................................................................................................66 a) b) III...................................................... Organized Public and private sector ...................... FAMILY PLANNING..... PRIVATE SECTOR ................................................................................................................. Ministry of Population Welfare................ 63 3.73 1.............................................62 B............................ 46 3.......................................................... THE POTENTIAL ROLE OF CIVIL SOCIETY ............... A.............................................. Devolution and local political environment...............................................................................................................................................................................................................................63 1................................ 54 3................. Abortion:............................................................................................................................65 b) Linkages with public sector.......................... C.................................................................................................................... 43 C.................72 b) Devolution and its Implications on District Health Services ..........57 b) Devolution and Reproductive Health Services................................................................................................................................ SEXUALLY TRANSMITTED INFECTIONS AND HIV/ AIDS ........................................................................................................... NGO/For non profit................................................................................. 2......................................67 LACK OF AWARENESS WITHIN THE COMMUNITY ........................................... 69 D.................................... 1............................................................... Response TO HIV/AIDS and STIs.................................................... 64 4..................................................................................................... II.............................................................. 72 a) Political Leadership:......................66 d) Support to NGO sector .................. 64 5..............50 Policy framework...............67 SOCIAL AND CULTURAL FACTORS....................................................................................................... Community participation....................................................... 57 a) Harmonization of RH services...........................68 Gender............................................................................................................................. 50 Population policy framework ............... Issues.......................................46 1............... Issues........ The offer of services................... 47 E........... A DETERMINANT GROUP : ADOLESCENTS...................................................................................................................................................................... Infertility:......................................58 c) Human Resource Development ....................................48 1.............................................................61 f) Health Management Information Systems (HMIS) .............. 56 4.............................................................44 1........................60 e) Logistics and availability of contraceptives ........................... 44 D...........................53 2.........67 AN UNDERUTILIZED PUBLIC SECTORS... 68 Male involvement....................................... Private health care..... Social Marketing Organizations........................ 42 Unmet need of family planning:............................ 46 2..................................................................................65 c) Affordability .............................................................................. 63 2.................................................... Cancers of Reproductive Tract................ 2.......................

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

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

Acronyms ADB AIDS AJK/NAs ARI AusAID BHU CBD CBO CBR CDR CIDA CPR DFID EAD EOC EPI EU FATA FBS FLCF FP FPAP FWC GDP GNP GoP HDI HDR HIV HRD ICPD ICPD/PoA IE&C ILO IMR IUD JICA KFW LHV LHW M&E MCH MIS MMR MOH MOPW MSU Asian Development Bank Acquired Immuno Deficiency Syndrome Azad Jammu & Kashmir/Northern Areas Ante Respiratory Information Australian Agency for International Development Basic Health Unit Community-Based Distribution Community-Based Organization Crude Birth Rate Crude Death Rate Canadian International Development Agency Contraceptive Prevalence Rate Department for International Development/UK Economic Affairs Division Emergency Obstetric Care Expanded Programme of Immunization European Union Federally Administered Tribal Areas Federal Bureau of Statistics First Level Care Facility Family Planning Family Planning Association of Pakistan Family Welfare Centre Gross Domestic Product Gross National Product Government of Pakistan Human Development Index Human Development Report Human Immunodeficiency Virus Human Resource Development International Conference on Population and Development ICPD/Programme of Action Information. Education and Communication International Labour Organization Infant Mortality Rate Intra-Uterine Device Japan International Cooperation Agency Kredi-tanstalt Fuer Wiedeeraufbau Lady Health Visitor Lady Health Worker Monitoring and Evaluation Maternal & Child Health Management Information System Maternal Mortality Rate Ministry of Health Ministry of Population Welfare Mobile Service Unit PAGE 10 O F 95 .14-APR-03 .

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 .

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

administrative and policy changes within a fluctuating political environment. 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.69 percent during the inter-censal period of 1981-1998 to 2. with an increasing demand for basic civil and social amenities.14-APR-03 . with 33 percent of the population living in urban areas. Since Pakistan is a signatory to the 1994 ICPD Programme of Action. 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. The subsequent section assesses the progress Pakistan has made in terms of demographic. The total fertility rate (TFR) has also exhibited a modest decline from more than five births per woman in the early 1990s to 4. housing. A . 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. in particular. In the post-ICPD period. RELATIONSHIP BETWEEN POPULATION.Chapter 1 POPULATION AND DEVELOPMENT I. However. (Source: Population Census Organization. About 50 percent PAGE 13 O F 95 . leading to a continually growing labour force. the population welfare programme frequently underwent structural. s uch as education. After the 1994 ICPD.16 in 2001. The population growth rate has declined from an average annual estimate of 2. 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. 1998 Census Report of Pakistan and Economic Survey 2001-02) and is expected to reach 220 million by the year 2020. It is. water and sanitation and infrastructure have not kept pace with the rapidly growing population. SUSTAINABLE DEVELOPMENT AND POVERTY While the number of employed people doubled between 1970 and 2002. DEMOGRAPHIC AND SOCIAL CHANGE Pakistan’s population increased from about 34 million in 1951 to nearly 132 million according to the 1998 census. Reproductive Health and Family Planning Survey 2001-02). B . The investments made in social sectors. ICPD CONTEXT Moreover. the number of unemployed people increased eight-fold during the same period.5 percent. health. and reproductive health. A consequence of high fertility rates is the unusually high number of young and adolescent population. therefore. social and macro-economic situation in the ICPD context. It was estimated as 146 million in mid-2002.8 births by 2000-01. the urban population has registered higher growth rates of 3. adversely affecting its commitment for realizing its objectives. which now requires much larger resources to create more employment opportunities for this section of the population.

PIDE). During 1990-91. This indicates that more than one-third of the total households in Pakistan are living below the poverty line. However. The population growth in Pakistan is still among the highest in Asia.6 percent of GDP.5 million in 2002. and high infant mortality rate. ranking it as 135th country of the world. on the other hand. 2001.522). as a result of Pakistan’s efforts to improve its macro-economic stability through the consolidation of its economic policies and human resource development. For females. Consequently.. it changed from only 20 percent to 30 percent during the same period. the unemployment rate rises to around 15 percent. has not witnessed any appreciable change. largely concentrating in capital goods machinery. PAGE 14 O F 95 . the value of human development index (HDI) in Pakistan is low (0. Although Pakistan appears to have made a breakthrough in achieving a declining trend in fertility and population growth rate. chemicals. C . Of these. more than 3 million persons are unemployed. The total labour force in the country has increased from 33. making it the sixth most populous country of the world and the third in the Asian region. Pakistan’s reasonably high growth rate of 6 percent as its Gross National Product (GNP) declined to 4 percent. 9th Five Year Plan 1998-2003. Changes in other major indicators relevant to population and development show that literacy rate has progressed at a very slow pace. If under-employment is also taken into account. e The trade deficit and the balance of tc. and possibly even lower to 3 percent. The inflationary pressures have. along with a large fiscal deficit of around 7 percent of GDP. and of semi-manufactured goods from 24 percent to 15 percent.of the total population lives in one-room houses with inadequate access to sanitation and sewerage facilities. Government of Pakistan). the country experienced sustained inflation ranging between 10 to 13 percent during the 1990s. are additional sources of concern for the country’s population and development programmes. during the 1990s. The per capita income was estimated at US $495 in year 2000-01 (Source: Planning Commission 1998. which in turn affected investment adversely and impeded economic growth. while the share of manufactured and industrial goods increased from 57 percent to 72 percent during the same period. The persistence of large fiscal and current account deficits during the 1990s were the main underlying cause of macroeconomic instability. The poverty level has increased from 27 percent in 1993-94 to about 35 percent in 1999-2000. indicating an unemployment rate of about 8 percent. the share of exports of primary commodities in the agricultural sector has declined from 19 percent to 13 percent. the annual growth rate of exports stagnated at 13.M. showing mixed results. fiscal management and improved supply of food items in the country. petroleum products. during the years 1999-2001. and this level is very close to 40 percent in rural areas (Source: Arif G. The composition of imports. inadequate coverage and access to primary health care and reproductive health services. Furthermore. however. tea. diminished to around 3 percent in recent years. increasing from about 35 percent in 1990-91 to around 45 percent in 1998 for the total population. With low levels of adult literacy. mainly due to tight monetary -4 policy. these changes are modest and below the desired level.6 million in 1995 to 41. edible oil.14-APR-03 . or around the value of US $ 8 billion. fertilizer. Measuring Poverty in Pakistan: A Critical Review of Recent Poverty Line. THE MACRO-ECONOMIC S ITUATION In the decade of the Nineties. 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. still leaving about 70 percent as illiterate (Source: Population Census Organization. 1998 Census Report of Pakistan).

9 percent in poor households. accentuating both poverty and related socio-economic problems in the country.7 percent during the same period (Table 1. the economic growth rates have not been adequate enough to benefit the poor.8 percent to 31. The percentage of literate household heads in non-poor households is 52 percent as compared with 27. Studies have also shown that poor households are higher in number in rural than in urban areas. lesser or no education. estimates are based on 2350 calories per adult at national level. 1998-99. Government of Pakistan.9 to 3.R. incorporates a comprehensive economic revival programme aimed at accelerating economic growth and social development (Source: Interim Poverty Reduction Strategy Paper.7 Rural 27. the market friendly policies including deregulation and privatization of public enterprises were adopted to promote investment. Official Poverty Line) * Estimates for 1998-2000 are based on 2250 calories per adult for rural areas.1).2 Urban 19. 2450 calories for rural areas and 2150 calories for urban areas (Planning Commission. Debt servicing as percentage of GDP has increased from 2. initiated in 2000-01. No. Vol.7 34. the Structural Adjustment Programmes that were pursued also affected various segments of population disproportionately.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. Table 1.payment position of the country during the 1990s has remained under pressure. However.5 billion in 1990-91 to $36. 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. unskilled labourers.14-APR-03 . 1997. and 2295 calories per adult for urban areas (Qureshi and Arif. 2002). The core principles and objectives of this strategy PAGE 15 O F 95 . The Poverty Reduction Strategy of Pakistan (PRSP).8 15.0 percent to 39. the proportion of poor households has increased from 27. with an average estimate of 4. The external debt burden increased from $15.5 percent of GDP or US $ 2.9 31.8 percent during the years 1992-1993 to 1999-2000. Despite the efforts made to reduce poverty during the past decade.1. Islamabad). and in urban areas.36. The Pakistan Development Review.0 28. The evidence shows that poverty-afflicted groups are generally the landless and small farmers. the u nemployed. * From 1993-99. (Source: Amjad and A.9 27. especially among the youth.5 billion by end-2002.0 33.7 39.8 Source: Arif (2001) Notes: Poverty estimates are based on basic needs approach.5 30.557 million per annum. In this regard. Macro-economic Policies and their Impact on Poverty Alleviation in Pakistan. and the aged in poor families.2 14. (Source: Government of Pakistan 2002).Kemal. The evaluation of these programmes point out their limited success in realizing the intended objectives. as well as resulting in rising levels of unemployment. female-headed households. Estimates reveal that in rural areas. Government of Pakistan).3% during the same period (Source: Economic Survey. and devote a large proportion of their consumption expenditure on food as compared to those in non-poor households. 2001). The poor households are generally characterized by larger family size.8 20.6 35. from 19. 2001.7 24. growth and productivity.

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

077.890 46. around 21 million males and 29 million females (10 years and above) are counted as illiterates in Pakistan. This percentage increased from 27 to 55 for males. including better reproductive health. the net enrolment rate. a major challenge for Pakistan’s development agenda is to achieve rapid economic growth. This indicates that about 50 million of the total population.0 32. being 47 percent for boys and 37 percent for girls. 18 percent have attained below primary and 51 percent have completed primary and middle levels. In this context. Enrolment of primary level increased from 10 million in 1990-91 to 18 million in 1998-99. which accounts for the over-age children enrolled at primary level.966 42.7 11.9 Population (10+) 14. is reduced down to 42 percent for total primary school age population (5-9 years).8 Females Population (10+) 121.411. 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. universal education and gender equality.751 Males Literacy Rate (%) 25. especially for girls at primary and secondary levels. and reduce its fertility and population growth rate to maximize its gains for population welfare.129.351.’98 The statistical evidence based on the 1998 census results shows that of the total formal literate population.2 35. and has PAGE 17 O F 95 . Although the female literacy level has almost doubled between 1981 and 1998.856 89. ‘81. enhance investment in its basic social sectors.049 Literacy Rate (%) 6.998 19. occupational structure of the labour force.1 30. and to the benefit of the poor.842. The corresponding gross enrolment ratio (GER) at primary level is estimated at 71-80 percent for boys and 61 percent for girls.450 26.460 30.953.941 23. and for females from as low as 8 to 32 during the same period (Table 1.2: Census Year 1961 1972 1981 1998 Trends in Literacy Rates (population 10 and above) by Sex: Pakistan 1981-1998 Both Sexes Population (10+) 26. LITERACY AND EDUCATION Attainment of education is one of the major components of human resource development which affects economic growth. adoption of new technologies. School enrolment has also increased considerably.2). HUMAN RESOURCE DEVELOPMENT G.0 Source: Population Census Organization.565.14-APR-03 . Of these. Literacy rates in Pakistan have increased gradually over the past decades from 18. personal income and demographic behaviour of population. F.260.910 56.7 21.1 54. ‘72.800 Literacy Rate (%) 16.889. to produce a well-trained and educated workforce.939 42.7 26. However. The ratio of female to male enrolment has improved at all levels of education during the past two decades. Population Censuses of Pakistan.4 percent in 1961 to about 44 percent according to the 1998 population census results.338.6 16.916.2 43. more than 90 percent have attained education up to matric and intermediate levels.towards these goals would reinforce the important goals adopted by the ICPD.100. especially education. 1961. Table 1.

7 23. PAGE 18 O F 95 . 2002). 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.contributed towards the lessening of gender inequities in education in recent years. middle and college level of education.2 Middle 25. Some basic facts about the country’s reproductive health situation indicate that more than 20. manpower capacity building. 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. are likely to improve the access to health care services and raise the health status of population (Ministry of Health. At primary. The recent improvement in school participation is attributable to increased investments in public primary schools which targeted at least one school per village. 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. 2002). aimed at reforming ten major areas in the health sector to reduce mortality. These include reducing prevalence of communicable diseases. while at secondary and university levels. especially in towns and cities.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. 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.5 College/Tertiary 35. most often attended by untrained personnel (Source: Reproductive Health & Family Planning Survey. 9th Five Year Plan 1998-2003. creating mass awareness about health and reproductive health matters.3). Table 1. correcting urban b regulating ias.5% of GNP to education during the development plan periods. Pakistan on an average has allocated 2.6 Source: Federal Bureau of Statistics: 1998.000 live births. About 33 percent of married women do not want to have more births after three children.9 71.5 Secondary 25. morbidity and malnutrition.4 64. However. improving primary and secondary health care services.8 49. H.14-APR-03 .5 University 28.7 52. and the opening up of significant number of private schools. a National Health Policy of 2001 with the motto of ‘Health for All’ was framed. especially among infants and mothers. To meet the challenges of the health sector. The contraceptive prevalence rate is around 28 percent (2000-2001) – one of the lowest in the region.1 37.0 58. private medical sector.8 49.7 32. Islamabad). improving nutritional deficiencies. National Institute of Population Studies. if implemented. which is below the UNESCO recommendation of at least 4%.000 women die each year due to pregnancy-related complications and maternal mortality remains between 300-700 per 100.9 68.2 40. females constitute more than 60 percent of male enrolments.4 21.7 51.5 35. Government of Pakistan.9 31. These reforms. Nearly 80 percent of deliveries take place at home.

688 Recurring Budget 10.7 0. Pakistan Institute of Development Economics. the real expenditure on health does not show a significant increase over the years (Macro-economics of Pakistan’s Economy. 2000). However. The majority of the labour force is employed in agriculture and related work (48%).077 5. if deflated by GDP growth and inflation rate. 2000-01).337 18. Of the estimated population of 143 million in the year 2001.81 22.190 18.7 0.4). with a crude economic activity rate of about 29 percent.316 16.485 6. 2001-2002 I. on an average. has allocated 0. the development budget on health is only a small fraction of the total.887 5.8 0.34 19.492 5. trade (14%) and manufacturing (11%) sector.944 6.08 24.717 % of GDP 0.7 percent to health during the previous development plans. followed by the services (15%).Pakistan. 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 16.28 25. LABOUR FORCE AND EMPLOYMENT Given the high fertility experience during the past decades. about 41 million are in the labour force.35 18.66 20. and a refined activity rate of 43 percent for all Pakistan. and the remaining are employed in construction.587 15.741 6. Moreover.857 13. transport and other sectors (Economic Survey.14-APR-03 . 5: Unemployment Rates Among the Youth Population: 1993-94 to 1999-2000 PAGE 19 O F 95 . Table 1. the current rate of growth of Pakistan’s labour force is over 2 percent per annum.44 11.7 Source: Pakistan Economic Survey.7 0. Table 1.7 0. and large amounts are spent on non-development/recurring expenditures to support the large infrastructure and salaries of the staff (Table 1.8 0.05 (million Rs) Development 5.

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. 21 percent in the case of females and 22 percent f males. The Khushal Pakistan Programme.0 6.4 1993-94 Urban 13. 2000). the Government of P akistan has launched many employment promotion programmes in recent years.1 14. Pakistan ranks low in terms of gender development index (GDI) with a value of 0. This has created one million temporary jobs in the rural areas and small towns with an expenditure of Rs. About 43 percent of population is below 15 years of age.7 3. As a result of the continuing high rate of population growth. and additional Rs.14-APR-03 . PAGE 20 O F 95 .2 1999-2000 Urban 19.Age Group Total 15-19 20-24 25-29 9. The small and medium enterprises (SMEs) programme launched in 2002 aims to provide small loans to the poor.2 11. The literacy rate for females is almost half of that of males. Some progress has been achieved in developing women’s capabilities and productive activities. Recent changes in the socio-demographic dimensions suggest that women have not only contributed but have gained from the development process. The gender gaps in literacy are more evident in rural than urban areas. child mortality.6 6. Further initiatives have also been undertaken to involve the private sector in expanding technical. females have a greater incidence of malnutrition. 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.0 5.4 9. the age structure of both women and men is heavily weighted towards younger and unproductive ages. vast gender disparities still exist in literacy and school enrolment rates. Currently. While in recent years women have considerably benefited from increased education facilities. J. it has been generally observed that gender discrimination prevails at all stages of life cycle. 15 billion allocated for the year 2002-2003. Both as children and growing adults.179 (UNDP. Recent census and survey or estimates indicate an improvement in sex ratio and female life expectancy at birth.1 Rural 7.7 Total 15.7 2. However. 24 billion.4 10.489 and a gender empowerment measure (GEM) with a value of 0. women can play increasingly important roles in reducing family size through realizing their reproductive goals.5 5. Pakistan fully recognizes the need for the enhancement of women’s participation in national development and their full integration into all development programmes.2 Rural 13. and lesser opportunities in access to education and employment than males. in accordance with the labour market needs and demands of the growing labour force. was launched in 2001 to improve poor people’s access to credit for their self-employment. implying that there is a better health coverage of the female population and a resultant change in their mortality rate. and has created about one thousand jobs.7 8. vocational and apprenticeship programmes for both men and women. and the existence of a latent demand for family planning in all population strata.3 Source: Labour Force Surveys: 1993-94 and 1999-2000 To deal with the severity of the problem. but in an uneven and a disproportionate way. With the beginning of fertility transition in recent years.6 5.

Increased urbanization is likely to change occupational structures.7 percent for low income countries.3 million metric tonnes in 1996 (Source: Human Development Report. Pakistan is also confronted with the problem of deforestation. lack of implementation of the quality standards for industrial pollution and the lack of defined property rights are contributing to environmental degradation in Pakistan. consumption patterns and life style. Low levels of education among women. the annual rate of deforestation was 2. Population pressures have also resulted in the over-use of land resources and acute water shortages. 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. 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. 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. crop cultivation. Estimates show that during 1990-95. This is damaging the ozone layer and entire ecological cycles affecting animal and plant life. fishery and livestock productivity. However. Such a situation has resulted in a massive soil and land degradation affecting agriculture. Besides overcrowding. 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.6 million metric tonnes in 1980 to 94. Moreover. Water-logging and salinity and the extensive use of extremely toxic pesticides in agriculture adversely affect land productivity and health of the people. therefore. Hence. Only 5 percent of the total land area is under forest. their productive work for the household and the economy remains invisible and undervalued. It is. There are few options for paid jobs in rural areas and most women work as unpaid family helpers on farms and agricultural activities. it has increased from 31. K . 1997). It is encouraging to note that the achievement of gender equity is recognized as a cross cutting theme for all development programs in Pakistan.9 percent per annum as compared with 0. POPULATION AND ENVIRONMENTAL ISSUES. 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.14-APR-03 . 2000). limited employment opportunities and cultural constraints in working outside the home combine to limit women’s employment in the formal sector. of which 30 percent is economically utilized (SDPI. particularly in the industrialized world. Besides the adverse effects of unplanned urban growth. the changing socio-economic conditions have resulted in increased participation of women in the wage sector.as only 20 percent of rural females were literate compared with 48 percent of rural males as reported in the 1998 census. especially in urban areas and in informal employment. Naushin. air pollution has increased markedly as a result of vehicular emissions and industrial pollution. and other economic activities on which human survival itself depends. necessary to plan the growth of cities in a scientific manner. PAGE 21 O F 95 . 2002. and the number of illiterate women (29 million) are about 60 percent of total illiterates in the country (Source: Mahmood. If measured in terms of carbon dioxide emissions. Gender Issues and Socio-economic Development. Country Report of Pakistan.

6 per cent during the 1961-72 inter-census periods. Urban population growth has accelerated and there has been a shift in the share of the provinces in the total population. large scale influx of war-driven Afghan refugees and entry of other illegal migrants seeking domestic employment.2. II. as compared to other countries in the region.14-APR-03 . This has brought about significant demographic changes. migration has had a pronounced effect: there has been substantial in-country migration. Pakistan was lagging behind in most human development. the annual population growth rate was still 3 percent and that a noticeable decline in the growth rate started only in the mid-1990s. A . OVERVIEW The demographic scene in Pakistan has two distinct features. 1 The State of Population in Pakistan. DEMOGRAPHIC AND REPRODUCTIVE HEALTH INDICATORS Even though at the end of the 1990s. 1987. it showed a gradual decline to 3. Similarly. In this chapter the changes and differentials that have occurred are examined under three demographic parameters.1.01 percent per annum. Table 2. Secondly.16% per annum. POPULATION GROWTH During the first half of the 20th century. mortality and migration.Chapter 2 POPULATION LEVELS. demographic and reproductive health indicators. the population of the country increased four times. namely. showing the crude birth and death rates derived from Pakistan Demographic Surveys. while during the second half. HUMAN DEVELOPMENT. Pakistan has made slow progress in reducing its total fertility rate. TRENDS AND CHARACTERISTICS I. However. As shown in Table 2. the annual rate of population growth in the country had peaked at 3. NIPS. fertility. PAGE 22 O F 95 . Firstly.1 percent during the 197281 inter-censal period and to 2. suggests that until the early 1990s. between the first post-independence Census of 1951 and the last census conducted in 1998. adding about a 100 million people. the population growth rate averaged 1. over time.7 per cent during the 1981-98 inter-censal period. By the time of the 1972 Census.2 percent at the end of the decade. Pakistan’s per capita GNP was higher than several of its immediate Asian neighbours. in the areas now constituting Pakistan. it has one of the highest population growth rate in South Asia: in mid-2002 it was estimated to be 2. reaching 2. Of special concern is the slow pace of improvement in these indicators in the country in the recent past. the growth rate averaged about 3 percent per annum.

3. Thus. Punjab on the other hand. 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) 3.6 2. Pakistan’s population is quite unevenly distributed among the four provinces. 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 1998.69 TABLE 2. Thus. the share of Punjab declined from 61 percent in 1951 to 57 percent in 1998. has only five percent of the country’s population and has a density of 19 persons per square kilometer. Pakistan Demographic Surveys.2 3.2 Source: Federal Bureau of Statistics.45 3.0 2. While the share of NWFP has remained somewhat similar (about 13.06 2. with only one-fourth of total land area of the country.67 3. This has partly been due to inter-provincial migration and different fertility rates.2: CRUDE BIRTH.352 Sources: Population Censuses of Pakistan. The provincial percentage share in the total population of the country has been changing. B .5 percent in 1951 to 5 percent in 1998. 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).817 42. is the most densely populated province. that of Balochistan increased from 3. it contains over 55 percent of population.TABLE 2.321 84. SPATIAL DISTRIBUTION OF THE POPULATION As shown in Table 2.978 65. PAGE 23 O F 95 .5 percent). 1: 1951 1961 1972 1981 1998 POPULATION GROWTH RATE IN PAKISTAN: 1951-2002 Population (000) 33. during the same period. Census Year Percent Annual Growth Rate during the Inter-censal period 1.14-APR-03 . Balochistan.80 2. which contains about 44 percent of the land mass. the share of Sindh has increased from 18 percent to 23 percent.254 132. On the other hand.

6 11. 1961- Population (in 000) 1951 Pakistan (Area 796.392 113 12.M. shows a typical pattern of higher percentage in the younger age groups.029 135 22.6 1. that during the recent past Pakistan’s birth rate has declined.612 183 57.TABLE 2.6 14.332 13 5.) Density per square Percent of Pakistan’s total population Source: Population Censuses of Pakistan 1961 42.3 8. confirming the findings reported in Table 2.566 19 5.5 5.491 92 3.847 68 4.190 Sq K. However.3 120 132 0.2 1. presented in Table 2.7 8.061 148 13. AGE-SEX COMPOSITION OF THE POPULATION Age-sex composition of the population.1 19.199 81 2.4 1981 84.095 Sq K.6 33.) Density per square Percent of Pakistan’s total population Islamabad (Area 906 Sq K.0 20.4 1.158 101 21.4 805 889 0.4 6.220 Sq K.M.0 17.0 47.8 6.4 1998 132.621 358 55.) Density per square Percent of Pakistan’s total population NWFP (Area 74.9 4.8 235 259 0. However.M.344 Sq K.500 124 59.187 3 3.0 25.0 73.1 2.744 238 13.1 4.521 Sq K.352 166 100.) Density per square Percent of Pakistan’s total population Punjab (Area 205.8 2.137 49 4.) Density per square Percent of Pakistan’s total population FATA (Area 27.M.978 54 100.253 106 100.321 82 100.385 4 3.374 59 19.6 30.0 3.054 43 17.6 340 375 0.3: 1998 POPULATION DISTRIBUTION AND DENSITY BY PROVINCES.433 7 3.3 1972 65.5 1.557 100 60.7 2.816 43 100.3 C .3.M. due to the persistently high birth rate in the recent past. it also reveals a smaller proportion of population in the youngest age group.914 Sq K.) Density per square Percent of Pakistan’s total population Sindh (Area 140.0 37.587 62 13.0 094 104 0.14-APR-03 .176 117 2.292 230 56.4 and in Figure 1.M.) Density per square Percent of Pakistan’s total population Balochistan (Area 347.M.440 216 23. the overall age structure of the population is heavily weighted towards PAGE 24 O F 95 .752 77 13.

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

4 1.0 1. During the period 1982-86 to 1997-2000. 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. indicating a need to focus both on pregnant women as well as neonates in the child survival strategy. these differential rates are useful for evaluating the country’s health policies and programmes.7 3.6 1.3 7.7 1.3 3. child and under five mortality.6 9. For example.4 100. post-neonatal period as PAGE 28 O F 95 .0 3.5 44. These findings suggest that the risk of death during early childhood is the highest during the first four weeks following birth.6 1.8 1.9 Source: Federal Bureau of Statistics.4 5.8 46.2 122.5 7.7 2.6 15.1 1. Pakistan Demographic Survey-2000 1.1 3. infant mortality rate (IMR) in the country had declined from 139 to 113 per 1000 live births. Table 2.1 19.3 8.0 3.9 Male 8.14-APR-03 .8 111.9 2. In the most recent period (1997-2000).4 1.3 8.4 2.2 1. infant. although it remained somewhat stagnant during much of the 1980s and was reported as 82 per 1000 live births during 1997-2000.6 Female 7.9 16. one done in 1996-97 and the second in 2000-01.4 3. compared with the remaining 48 weeks of the first year. an interesting pattern of sex differential in early childhood mortality is reported.4 45. post-neonatal.5 8. The proportion of neonatal deaths is higher compared to post-natal deaths. When further disaggregated into different categories of neonatal. INFANT AND CHILD MORTALITY During the 1960-80 period.7 18.0 1.2 1.6 2.6: AGE & SEX SPECIFIC DEATH RATES (PER 1000). the mortality rates for males are higher during the neonatal.2 4.TABLE 2.3 2. PAKISTAN.7 3.3 10.0 11.7 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).7 5.7 1. child mortality declined from 25 to 20 per thousand live births and under-five mortality has declined from 136 to 103.

Post-neonatal Mortality: probability of dying between the first month of life and exact age one year. they are at a higher risk of dying than the male children.14-APR-03 . having survived the first year.well as during infancy. suggesting that less attention is given to the overall health of girls and. and when they received both antenatal and post natal care during the period of pregnancy and subsequent childbirth. Under-five Mortality: probability of dying before the fifth birthday.7: Sex and Period EARLY AND LATE CHILDHOOD MORTALITY RATES BY SEX. therefore. Pakistan Reproductive Health and Family Planning Survey. thereafter the child mortality rate is substantially higher for females. The IMR is reported to be lower in the major urban areas. However. particularly among mothers with middle or higher levels of education. as expected. TABLE 2. having survived the first month. 2000-01 Neonatal Mortality: probability of dying within the first month of life. TABLE 2.8: DIFFERENTIALS IN INFANT MORTALITY RATES BY BACKGROUND CHARACTERISTICS: 1992-96 PAGE 29 O F 95 . could be reflective of the relative absence of quality maternal child health care services and facilities in the province. Child Mortality: probability of dying between the first and fifth birthday. presented in Table 2. Differentials in IMR. Infant Mortality: probability of dying before the first birthday.8. 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.

2000-1 2.8 births per woman.1 6. it is notable that the gap between the rural and the urban areas has widened substantially.5 to 3. when the total fertility rate (TFR) was about 6 births per woman.9: TRENDS IN TOTAL FERTILITY RATE.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.4 4. During this period.4 in the major urban areas and from 6. 1984-2000 Area Major Urban Other Urban Rural Total 1984-85 5.9).2 6.8 5.0 5. FERTILITY DIFFERENTIALS As shown in Table 2.9 4.5 6. whereas in much of the rural area such services remain scarce. which are more developed economically as compared to the two less developed provinces of PAGE 30 O F 95 .2 5. FERTILITY 1. Pakistan Reproductive Health and Family Planning Survey. Since then a gradual decline in TFR has led to 4. 1996-97 F. the TFR declined from 5.14-APR-03 .4 1992-96 3.2 to 5.4).7 5.4 4.0 1986-91 4.0 in other urban areas. NGOs and the private sector (social marketing and commercial sales).6 5. Also urban areas have been provided regular family planning services by the government. Pakistan Fertility and Family Planning Survey. TABLE 2. There are several reasons for this rapid decline in urban fertility.10. a slightly lower fertility is reported in the two provinces of Punjab and Sindh.1 to 4.9 5. During the 1985-2000 period. whereas in the rural areas the decline has been quite modest (from 6. The most notable change in the TFR has occurred in the urban areas of the country. Foremost among them is the higher level of female education and higher age at marriage among urban women.8 Source: National Institute of Population Studies.4 1997-2000 3. which was reported at the end of the decade (Table 2. TRENDS IN FERTILITY The fertility rates in Pakistan remained high until the 1980s.

6 4. Over two-thirds of these recent migrants settled in urban areas where they constitute 6. 2000-01 G. 1. 1986). as compared to 1. In the rural areas of Punjab. INTERNAL MIGRATION With the help of information on duration of continuous residence. Continuation of this pattern has been confirmed by 1998 Census as well. Less than 30 percent settled in the Punjab and less than 10 percent settled in the NWFP.3 Source: National Institute of Population Studies. 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. MIGRATION There are three main aspects related to migration in Pakistan: (a) inter-provincial. (b) rural to urban. over 40 percent had originated in Punjab and over 37 percent in the NWFP (Table 2.8 4. Of all those who had migrated within the country. which is clearly indicated when TFR is classified by the economic status of the household. the former on average having a TFR which is about one-third higher than the latter.0 3. Pakistan Fertility and Family Planning Survey.7 5. the number of persons who migrated during the ten years preceding the 1998 Census was estimated at 4 million.2 3. These are discussed in this section. This suggests that in Punjab rural-to-rural migration is more prevalent.8 5. and (c) international. Since the 1950s.14-APR-03 .10: FERTILITY DIFFERENTIALS BY PROVINCE EDUCATION LEVEL AND SOCIOECONOMIC STATUS IN PAKISTAN. However.7 4.6 3. This difference could be due to inaccessibility to contraceptives by the poor.Balochistan and NWFP.4 5.5 percent in the rural areas. Sindh PAGE 31 O F 95 . the percentage of recent migrants was about twice that of the other three provinces.1 4. TABLE 2. Urban areas of all the four provinces combined had 5 to 6 percent of their population classified as recent migrants.1 5.8 3.3 percent of the population.7 4. 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. overall illiterate women report substantially higher fertility than those who have completed even up to middle or higher levels of education.11). Sindh has been receiving migrants who have mainly originated in the Punjab and NWFP provinces (Karim.2 3.

6 2.439. the urban population doubled 17.0 5.671 500.0 0. This phenomenon may contribute largely to the rapid pace of urbanization in the country.331 55. which is much higher and faster than in the rural areas.894 166.893 17.290 30.12 rural-to-urban migration has resulted in an upward growth of population in the urban areas.0 326. The provision of basic amenities in urban areas has not kept pace with the growing PAGE 32 O F 95 .352.0 4.0 13. 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.7 * -141.0 1. Another important feature of migration during the past ten years is the pattern of intra. About 50 percent of those who originated in the NWFP settled in the Punjab and over 40 percent in Sindh.0 0 Source: Population Censuses of Pakistan.4 467.074 154.830 130.083 -1.599 originated in AJK /Northern Areas and 522.858 100.5 percent. 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).414 Pakistan 132.414 41.2 7.2 4.819 56. 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.4 5. 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 73.885 805. One-sixth of those settled in Punjab had originated in the NWFP and only 33 percent in Sindh.159 369. URBANIZATION AND GROWTH OF CITIES As shown in Table 2.130.645 6.297 100.666 did not report their place of origin.968 11.858** 100.0 1.847 -337. TABLE 2. Between 1951 and 1998.received the majority of these migrants.176.223 81.6 23.9 44.334 * 28.565.11: DISTRIBUTION OF RECENT INTER-PROVINCIAL MIGRANTS BY ORIGIN. On the other hand. 108. 1998 *Information on In-migration to FATA not available.130.743.736 55.9 14. ** Additional 389.883 -45. over 75 percent of those originated in Sindh were settled in Punjab and less than 5 percent in the NWFP.376 418. The urban population has grown over seven times from about six million in 1951 to about 43 million in 1998.621.451 45.14-APR-03 . about four times of those who had originated within the province.4 11.0 1. 2.7 percent to 32. This rapid urbanization has already resulted in Pakistan’s being the country with the highest proportion of urban population in South Asia.and inter-provincial migration in the country.5 37.235 3.062 persons originated in other countries.

On the other hand.8 0.9 22. on an average.8 Pakistan 3.8 2.3 3.1 3.5 3.8 Balochistan 4. the overall rate of natural increase in the urban areas of Pakistan was reported as 2.5 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.9 3. during 1981-98.3 3.3 2.12: Estimated Contribution to Population Growth due to Migration During the 1980s and 90s Province Urban Areas Average Average Growth Natural Rate* Growth Rate** (19811998) (1) (19841997) (2) Difference in Growth rate due to Migration Rural Areas Average Average Growth Natural Rate Growth Rate (19811998) (19841997) (6) Difference in Growth rate due to Migration Actual Percent Actual (7)=(5)(6) -0. Based on the Pakistan Demographic Surveys conducted during 1984-97. or about 24 percent of the total urban growth was due to migration.0 0. 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.3 per cent.4 -59.13. the twelve largest cities recorded an annual growth rate of 3.8 20. while the average rate of population growth during the intercensal period was only 2. Table 2.6 2.7 2.5 percent and during this period their combined population increased from 13. adding to a host of problems through the increasing slums within cities and townships.2 2.6 0.9 2.5 2. the rate of natural increase in the rural areas was 3 per cent per annum.7 Percent (8)=(7)/(6)*100 (3)=(1)-(2) (4)=(3)/(2)*100 (5) Punjab Sindh NWFP 3.0 -41.6 per cent.2 percent higher population growth rate per annum than the rural areas.6 -24.9 -0. 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 1998.8 2.9 2.7 -0.8 million to 24.2 -0.7 2.0 3.7 0. urban areas of the country.7 23.6 -31. Apparently the rural areas of the country lost about 32 per cent of their population due to migration.0 -27. As shown in Table 2.1 2.9 PAGE 33 O F 95 . This implies that 0.2 40.14-APR-03 .8 percent.6 1.6 -1. recorded over 1.urban population.5 22.

It dipped to as low as 58. In the 1998 Census. both the governments signed an agreement on the repatriation of about 3 million Afghan refugees over the next three years.9 1132. those who emigrate unofficially are generally not accounted for.5 2008. about one million people mainly from Bangladesh are believed to have also settled in the country.000 during much of the rest of the decade for which PAGE 34 O F 95 . 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 13.9 1409.0 5443.0 529. Sri Lanka and India as well.000 Afghans re-entering Pakistan. and as a result of the Bonn Agreement between Afghan groupings in exile.7 million Afghan refugees were living in Pakistan by the end of the 1990s.000 in 1992 and remaining between 114.43 2. 1998 Census [note that totals are rounded]. a conscious decision was made not to include Afghan refugees. according to UNHCR sources.000 persons annually.694 Population (000) 1998 9339.2 million refugees are living in camps and another 2 million dispersed in the cities.000 to 155.million. TABLE 2.4 421. the trend in emigration. although newspaper reports suggest that there are between 2 to 3 million of them are now living in the country. Based on the Ministry’s records. basic civic amenities remain scarce and the municipalities are unable to cope with the rapid increase in their population.71 1.30 5. The number of emigrant workers increased substantially during the early 1990s peaking at 191. During the visit of an official Afghan delegation to Islamabad. 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. about 3. the installation of the Interim Administration in Kabul. led to the return of close to a million refugees to Afghanistan.2 458. It is estimated that about 1. The Ministry of Labour and Overseas Pakistanis keeps records of all those workers who emigrate from Pakistan through official channels. uncertain conditions in Afghanistan saw about 200.66 3. suggests a substantial decline beginning from 1983 when it averaged about 120. 655 Inter-census Growth rate (percent) 3.50 3. There is a small number from Iran.80 3. Besides the Afghan refugees living in the urban areas.13: Rank 1 2 3 4 5 6 7 8 9 10 11 12 POPULATION OF TWELVE LARGE CITIES OF PAKISTAN.14-APR-03 .15. in the census count. A newly established organization.8 1197.4 1166.92 5.58 3.60 3. 3.98 3.8 565. According to the statistics maintained by the Ministry of Interior.52 Source: Population Census of Pakistan. as shown in Table 2. In most of these cities.77 2. Following the events and situation in Afghanistan in the post September 11. has begun the difficult task of registering refugees and unregistered aliens in the country. However. 2001 period.5 982.94 2. and other illegal aliens. However. the National Alien Registration Authority (NARA).5 24.000 by 1985 and then rose again to early 1980 levels.

although population growth rate is high. from the foregoing analysis. Summing up.14-APR-03 . there is a trend of large scale migration to the cities in search of employment adding to the problems of poverty and urbanization. Secondly. PAGE 35 O F 95 . However. there are variations in fertility decline: it is more in urban areas as compared to the rural areas. fertility is significantly higher among those classified as poor and very poor. three main conclusions can be drawn. 23. semi-skilled and unskilled jobs and are a source of substantial inflow of foreign exchange. Lastly. 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. Firstly.4% of population is within the age group 10-19 years which underscores the need to meet the requirements of the adolescents. and it is highest in Balochistan and NWFP as compared to the other two provinces. Thirdly. The vast majority of Pakistani emigrants go to the various Middle-Eastern countries where they work at a variety of skilled. and it again becomes high as compared to the males between the ages 30-34 which are the stressful years of child-bearing.data is available. there is evidence that a fertility transition has set in.

Unfortunately. A large number of these women suffer unnecessary risks associated with childbearing. and another study from Aga Khan University 3 Interim Population sector perspective plan 2012 Pakistan Fertility Survey.4 in 1986-915. Hospital-based studies over-or under-estimate the MMR. REPRODUCTIVE HEALTH IN PAKISTAN Introduction: At Pakistan’s last census in 1998 the population was 132. The Total Fertility Rate (TFR) for all of Pakistan was recorded at 6. about 5. Inspite of gradual decline of infant mortality in the country. 8 9 PAGE 36 O F 95 . 2000-2001: Preliminary Report”.000 live births (circa. fertility is higher in the rural areas (TFR of 5. These studies also suggest that the levels and causes of maternal mortality vary between districts. for all of Balochistan (6. Almost 80% of births occur at home. The average TFR for the last four years is estimated at 4.14-APR-03 .2). depending upon accessibility of emergency obstetric care (Table 3. The community-based studies would suggest that the MMR in Pakistan ranges between 300 and 700 per 100. Each year.7) and among uneducated women (6.4 million women go through pregnancy and childbirth. Pakistan has an estimated 33 million women of reproductive age.000 live births. according to PFFPS 1996-7). 1976 Pakistan Demographic and Health Survey.86.69 %3.5 million new births. the perinatal mortality rate has remained high with no significant change. 1991 Reproductive Health and Family Planning Survey of 2000-01 4 5 6 7 PIHS 98-99 National Institute of Population Studies.2 in 1970-754. resulting in 4. J Pak Med Assoc 1985 Aug. Two extreme examples are a study done in Civil Hospital Karachi in 1979-19839.CHAPTER THREE REPRODUCTIVE HEALTH AND FAMILY PLANNING I. there is n reliable national MMR figure available in Pakistan. usually attended by untrained birth attendants. However.1). which reported MMR of 2736 per 100. Ahmed Z.35(8):243-248. MATERNAL AND INFANT MORTALITY 1. with the exception of o an indirect estimate of 533 per 100. depending upon the population they serve. “Maternal mortality in an obstetric unit”. A . indicating a high burden of disease and death. “Pakistan Reproductive Health and Family Planning Survey.7.0). About two-thirds of pregnant women receive no prenatal care7. and 5. 1990)8.4 million with an inter-censual growth rate of 2.000 live births (Table 3. 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.

Unfortunately. 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. J Pak Med Assoc. 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. particularly in the rural areas. Berendes HW. A small but significant percentage of maternal mortality is attributed to unsafe induced abortions. Sci. which reported the MMR of 20 per 100. Soc. Med 1998. 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. 2001. there have been significant and considerable improvements in the access and quality of emergency obstetric care available to population. 51 (3): 109-111. “Contextual determinants of maternal mortality in rural Pakistan”. Midhet F. toxemia of pregnancy. Karachi. namely: postpartum hemorrhage. “Causes of reproductive age mortality in low socioeconomic settlements of Karachi”. (46) 12: 15871598. Berendes HW. 11 Fikree F. It may. 1993. therefore. Jaleel S. Moreover. Since independence. “Maternal deaths in a developing country: a study from the Aga Khan University Hospital.14-APR-03 . be assumed that maternal mortality levels might have declined considerably over the last few decades. MMR in various Pakistani sites. Lakha SF. Table 3. Pakistan 1988-1999”. 43 (10): 208-212.1. Becker S. however. particularly in the rural areas. there are no hard data to substantiate this assumption. the decline in fertility may be directly associated with a decline in maternal mortality rate. obstructed labor and puerperal sepsis. J Pak Med Assoc. Hamid R.Hospital of Karachi10. Available data do not permit estimation of trends in maternal mortality levels. 12 PAGE 37 O F 95 . Karim MS.000 live births among booked clients during 1988-1999. 10 Midhet F.

certain process and output indicators can be used for monitoring MCH interventions. data on the prevalence and determinants of obstetric complications are scarce and unreliable. However. Becker S. Pakistan Fertility and Family Planning Survey 1996-1997.2. two-thirds of pregnant women do not receive any prenatal care15. Hakim A. Islamabad. In a study at the Pakistan Institute of Medical Sciences. Proceedings of the First Annual Conference of Population Association of Pakistan.Table 3. “Contextual determinants of maternal mortality in rural Pakistan”.14-APR-03 . an Indicator of Maternal Care”. 2002 (under publication). “Severe Maternal Morbidity at Pakistan Institute of Medical Sciences: The Near -miss Concept. Pakistan. 18 Mehmood G. Berendes HW. genital fistula. World Health Organization. (46) 12: 15871598. For example: the prevalence of severe anemia among pregnant women was about 10% in 198814. Med 1998. The Aga Khan University and Population Council. 16 Ibid. Soc. A Review of Research on Maternal Health. prolapsed uterus. 19 PAGE 38 O F 95 . 2000. Unfortunately. rupture of the uterus and puerperal psychosis18. Available data point towards these indicators being poor. Cleland. 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.5% of all deliveries conducted at the hospital’s Obstetrics Department were regarded as ‘near-miss’ – defined as a life-threatening obstetric emergency19. National Institute of 15 Population Studies. 1999-2001. J. 1988. Islamabad. over 80% of all deliveries occur at home16. December 1998. Sci. and only 18% of deliveries are performed by skilled professionals17. 17 Saleem. 13 14 National Institute of Health. Bhatti MH. Sarah. National Nutrition Survey . et al. Karachi. Midhet F. Cause-specific MMR by access to emergency obstetric care (EmOC). about 3. suggesting high levels of maternal mortality. 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. small-scale studies and hospital-based information suggest high prevalence of anemia. 2.

23 24 Health policy 1997 PAGE 39 O F 95 . breastfeeding and immunization). a consistently high perinatal mortality rate indicates high levels of maternal mortality and low quality and accessibility of obstetric care available to women. The only major intervention directly related with obstetric care during this period was that of training a large number of traditional birth attendants (Dais). A 15-days intensive Dais Training Program was developed and imparted in all rural areas of Pakistan. MAJOR ISSUES IN SAFE MOTHERHOOD: During the 1970s and 1980s. the perinatal mortality rate (stillbirths and infant deaths during the first week after birth) has also remained high – ranging from 56 to 72. “Role of traditional birth attendants in improving reproductive health: lessons from the Family Health Project. 4. In 1996-7. skills and performance of Dais for sometime after training. There is no evidence that Dais training programs in Pakistan have worked to reduce maternal mortality. Many professionals have questioned the impact of Dais training on the maternal health indicators in developing countries. it is believed that these programs failed to cause a significant decline in maternal mortality. the emphasis of the national MCH program shifted more toward child survival strategies (growth monitoring. although many programs have reported improved knowledge. the reduction in the neonatal mortality rate was from 94 to 55 during the same period21. 21 22 Islam A and Malik FA. 2001-02 Save the Children USA. State of the World’s Newborns: Pakistan. Generally. their quality of tutors. 20 Economic survey of Pakistan 20002-3 Integrated Household Survey – Round IV. Even with a decline in the IMR. Sindh”.000 traditional birth attendants were trained in safe delivery care and early recognition and referral of cases with common obstetric danger signs. INFANT MORTALITY: Although infant mortality rate (IMR) in Pakistan has declined considerably since independence in 1947. J Pak Med Assoc 2001 June: 51(6): 218-222. and about 53. the quality of their product is not of standard. mainly because there was no follow-up. Similar training programs were organized in other provinces. During 1992-1999. therefore. and. based upon various small studies22.3. the rate of decline is slow compared to most developing countries. training. Because many risk factors of perinatal mortality are the same as those of maternal mortality. Although most districts hospitals have midwifery schools attached to them. 2001. Pakistan has an IMR of 82 infant deaths per 1000 live births20. neonatal mortality (death of children within first month after birth) has remained high: While the IMR declined from 178 in 1950 to 95 in 1992.14-APR-03 . 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. there were about 2130424 trained midwives (including nurses) in the country. oral re-hydration therapy for childhood diarrhea. Moreover. supervision or support system for the Dais trained under this program.

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

10. Pre intervention and post intervention baseline surveys (qualitative and quantitative) will be conducted in control and intervention areas. has incorporated Dais training and community health education in MCH in its primary health care project in rural areas of Sindh province. Columbia University of New York. The project has recorded significant increase in obstetric referrals from the project site. and nearly 76% know a place for female sterilization versus only 37% in 1990-9127. which was conducted during 1989-1993 in urban and rural areas several districts. Preliminary results indicate a significant reduction in MMR in the project area. training necessary staff and strengthening of district midwifery schools. the project will assist in community sensitization on maternal health. the Association has a wealth of data that can be used to evaluate their interventions. 1991. and 96% of currently married women are aware of at least one method26. 4. in collaboration with UNICEF. The results are awaited. has recently concluded its community outreach project that facilitated women’s access to EmOC through mobile clinics and training of lady health workers. in collaboration with the UNFPA. NIPS/IRD-Macro: Pakistan Demographic and Health Survey. Even though the projects are not designed as operation research studies. 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. Ministry of Health in five districts. FAMILY PLANNING Medicins du Mond. developing a referral system. up-gradation of selected RHCs and THQs for basic and comprehensive EOC.2. with an objective to increase health services utilization by women and improve women’s access to EmOC. 2001. Islamabad. UNFPA is assisting the Government of Pakistan in training selected Lady Health Workers from the National Programme on PHC/FP in midwifery skills. there has been a substantial rise in knowledge about different FP methods. 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. 3. a NGO. multi-district community-based study of maternal and infant mortality. In addition. The project has successfully increased health services utilization by women and percent of deliveries performed by skilled birth attendants. 6. is currently implementing a project to strengthen EmOC services at secondary care hospitals in selected districts of Sindh province. 27 PAGE 41 O F 95 . Aga Khan University of Karachi has to its credit the only large-scale. 5. Their knowledge about where to obtain modern contraceptives is also quite high. 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. In recent years. 7. 26 NIPS: Pakistan Reproductive Health and Family Planning Survey. APPNA Sehat is another NGO that has trained Dais and provided health education to women and families in the Murree district of Punjab. 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. Project will be implemented by the National Programme on PHC/FP. B. HANDS. The MCH Department of the Pakistan Institute of Medical Sciences.14-APR-03 . The catchment area of this worker would be 2000-5000 rural population depending on the geographical considerations. The study was conducted in rural Punjab. 9.

4 0. the facilities and community-based distribution systems of the MOH and MOPW offer oral contraceptive.4 1.2 7922 PFFPS30 1996/97 23. nearly 45% of all acceptor couples rely on methods that require the initiative or compliance of husbands. one type of IUD. Pakistan Fertility and Family Planning Survey.1 1.0 5.0 1.1 2. condoms and voluntary surgical contraception.7 1.8 0.5 2.0 0.3 6364 PCPS29 1994/95 17.5 6370 Results of the five studies reveal increasing use of all modern methods.4 1.7 5.1 2.5 7405 PDHS 1990/91 11.0 1.8 1.2 0.6 1.9 4.9 16.8 0.0 2. CONTRACEPTIVE PREVALENCE Among modern methods. According to the PRHFPS survey 2000-01.14-APR-03 . The most popular temporary method is the condom. although it has a low demographic impact because the majority of women seek it after completing their family size (four or more children).0 7.0 5.1 0. 1991.6 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 9.3 0.5 0. closely followed by withdrawal.9 0.7 3.0 2. 29 30 PAGE 42 O F 95 .1 4.8 9. Table 3.7 2.1 7.6 0.5 7582 PRHFPS 2000/01 27.0 7.3 0.3 1.5 6.6 20.9 3.2 1. 28 Pakistan Contraceptive Prevalence Survey 1984-85 Pakistan Demographic and Health Survey.9 1.0 0. This is an interesting finding and is discussed in some detail below.0 0. The less effective traditional methods of family planning are also quite popular.9 0.3. while IUD also makes an important contribution.6 0. The following Table shows the progression in the use of contraception since 1984.0 4.6 3.2 6. two types of injectables.6 0.1.0 3. 1996-97. Female sterilization remains the method of choice.8 12.0 0.4 0.6 5.5 0.6 0.2 1.

and (2) the economic. et al. 32 See. 1997 Ibid. including 12. perhaps with influence from the husband. 2.14-APR-03 . lack of faith in the health and family planning delivery systems. This hypothesis is supported directly or indirectly by many other studies. The USLS found that contraceptive continuation rates for condom. respectively)31. including those relating to menstruation and sexual relations. Fewer women reported similar complaints related to natural methods. Generally. studies have revealed little inter-spousal disagreement between husband and wife on fertility issues. provider behaviour. “On the Dynamics of Contraceptive Use in Pakistan”. and were closely comparable with those for IUD. especially with regard to sexual relations. Sathar and Casterline. Women having surgical sterilization were quite satisfied with the method. lack of follow-up services.1% women who wished to delay their next pregnancy and 20.32 hypothesize that this may be a result of only those couples using the modern contraceptives who are resilient and determined to use them. 33 34 Pakistan reproductive health and family planning survey 2000-2001. perceived or real fear of undesirable side effects. continuation rates for the pill and injection users were much lower (55% and 46%.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.722 women). social and physical costs of using modern contraceptive methods.9% who wanted no more children. as perceived by women35. Ibid. UNMET NEED OF FAMILY PLANNING: The survey of NIPS34 reported a total unmet need of family planning of 33%. UNFPA commissioned the Population Council to conduct the User Satisfaction and Longevity Study (USLS). 31 Miller PC. Contrary to popular beliefs. “The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women” Population Council. “The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women” Population Council. Miller et al. for example.. social taboos against the use of family planning. In 1997. A distrust on modern methods of contraception. could be the main reasons that can explain both the high levels of unmet need and relatively high rates of use of traditional methods. the contraception use continuation rates for modern contraceptives were high as compared to other developing countries and were certainly within international norms. 35 36 PAGE 43 O F 95 . etc. 1997. withdrawal and periodic abstinence were between 75 and 80 percent at the end of the first year. Interestingly. which reported the findings from a national sample of 2. 1999. and this disagreement cannot be regarded as sole explanation for unmet need 36. including those reporting the causes of high unmet need of family planning 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. Population Council. Many users of female methods complained of negative 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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Karachi): “Cancer incidence in Karachi. All these factors contributed to poor cure rates among cancer patients in Pakistan. 43 PAGE 47 O F 95 . Rahim A. which found the rates of 137/100. Zaidi SH. Another study42 in Karachi found that patients of breast cancer present at a very later stage as compared to the Western countries.” Int J Cancer 2000 Feb 1. Hassan SH. Secondary infertility is associated with unsafe abortion and reproductive tract infections.Adequate data are not available to estimate the incidence and age-standardized rates (ASR) for cancer among men and women in Pakistan.52(4):155-158. Parkin DM. 41 Malik IA. J Pak Med Assoc 2002 Apr. About 93% of the 506 patients studied over a period of five years (1994-1999) had discovered the lump in the breast accidentally. including a high prevalence of family history of young age breast and/or ovarian cancer and a younger age at presentation.000). particularly STIs. Sana S. (National Cancer Institute Karachi): “Clinico-pathological features of breast cancer in Pakistan”. J Pak Med Assoc 2002 Mar. Sankaranarayanan R.85(3):325329. 3. Small-scale studies estimate that prevalence of primary infertility is 3.000) and ovarian cancer (ASR = 10/100. Epithelial ovarian cancer patients were found in one study41 to have unusual presenting features. 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.14-APR-03 . These findings indicate that genetic predisposition plays a greater role in the causation of ovarian cancer in Pakistan. National data on infertility is not available.29 Suppl 1:4-8. INFERTILITY: In Pakistan infertility is usually held to be the wife’s problem.000 for women. as compared to Western countries.4% and secondary infertility 18. Bhurgri A. The only study on incidence of cancer was conducted in Karachi South District40. Gan To Kagaku Ryoho 2002 Feb. the reason for not contacting a medical care provider included poor socio-economic status and illiteracy. AI Medical College Lahore): “Cancer treatment in Pakistan: Challenges and obstacles”. Associated co-morbid conditions were a major cause in delay in cancer treatment. (Department of Oncology. A majority of patients did not receive adequate treatment. (Dow Medical College and Karachi Cancer Registry. A study of over 3.4%.000 confirmed cancer patients in Lahore43 determined that a majority of the patients presented at a relatively advanced stage. 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. Pakistan: first results from Karachi Cancer Registry. followed by cancer of the oral cavity (ASR = 14/100. Among women. (National Cancer Institute Karachi): “A prospective study of clinico-pathological features of epithelial ovarian cancer in Pakistan”. 40 Malik IA. breast cancer was the commonest (ASR = 52/100.000).52(3):100-104 42 Aziz Z.000 for men and 163/100.

activities and responsibilities that occur as individuals move from childhood to adulthood distinguish adolescents as a formative time with significant consequences for individuals. Zahir “Reproductive health indicators in Pakistan: Experience of a pilot study”. occurring during the second decade of life.3% of the total population.often treatable. as will the proportion of the population represented by adolescents. Serious attention to adolescents in Pakistan should be accorded due to their large (and growing) numbers. This cohort is estimated to increase by 9. due to the population momentum built into the current age structure. Population Council December 2000 PAGE 48 O F 95 . Though adolescents is most often associated with physical changes accompanying puberty. emotional. In: Pakistan’s Population Issues in the 21st Century: Proceedings of the Annual Conference of Population Association of Pakistan.23 mill by 2010.14-APR-03 . communities. A DETERMINANT GROUP: ADOLESCENTS The realization that adolescence is a separate stage in life has acquired attention only in very recent times.between the ages of 10 and 19. The adolescent population 10-19 (30. The referral rates for infertility were higher in rural area (3%) than the urban area (1%)44 . However. the diagnosis and referral of infertility cases is also very low in Pakistan. mental. Pakistan currently has the largest group of adolescents in its history with nearly 30 million individuals45 – almost a quarter of its population . and the country46. 2000. the transformation in social roles. This figure will continue to grow. Hakim A and Z. 44 45 Population Census 1998 46 Adolescent Girls and Boys in Pakistan: Valerie L.Durrant. and social maturation. In a small study in Jhelum District of Punjab. while the referral rate among the infertile couples was just about 15%. and is a complex phase of physical. the total prevalence of infertility was estimated at 13% (15% in urban area and 10% in rural area). E.10 mill to a total of 39. expectations.13 mill) in 1998 constituted 23. Karachi. families. Adolescence is defined as the period of transition from childhood to adulthood.

This cohort is estimated to increase by 9. The women in reproductive age 15-49 (28.32% of the total population. by the year 2010. there will be an increase of 7.8 million) in 1998 constituted 22% of the total population. The 0-14 cohort (55. Adolescent marriage particularly among girls is still common in Pakistan. In the age group 15 – 19 years 3 to 4% of males and 17% females are married. A clear gender difference remains in the timing of marriage. Likewise the adolescent population 10-19 (30.5 and has leaped from 23.54 million) in 1998 constituted 43% of the total population will increase to 62. The singulate mean age of marriage (SMAM) has increased from 16. while in the 20 –24 years age category 17 % of males and 54% of females are married.79 million.23 million with a relative decrease of 0. A closer look at the married adolescent population in Pakistan reveals interesting findings. For boys the current SMAM is 26.25 million in absolute number but would be decrease by 6.14-APR-03 .10 million to a total of 39.56 million to a total of 42.36 million with a relative increase of 2.7 in the 1960s to 22 years in 1998 for girls. There is also an urban/rural difference in adolescent marriage practices. However the age of marriage has been rising in the past few decades.13 million) in 1998 constituted 23. Thus. This cohort is estimated to increase by 13.38% of the total 2010 population.48% of the total 2010 population.3 in 1961. It is estimated that the population of Pakistan will increase to approximately 171 million by the year 2010. 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 .25% in relative percentage of the total population. 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.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.

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

the program received open and sustained political and administrative support. This was to be achieved by pursuing multi-sectoral approach. The program was backed by sustained promotional campaign through mass media and supportive events and activities with the involvement of private sector. The scheme was experimented to improve low coverage in the rural areas. National Assembly and Provincial Assemblies. seminars. resource allocation and regular reviews as part of a social sector undertaking. restoration of more effective IEC campaign. Social Marketing of Contraceptives program was introduced and National Institute of Population Studies was established for undertaking research on population and development. with a view to set trends for rural areas to emulate. Political commitment became visible and PAGE 51 O F 95 . Meet-the-Press sessions. continuous motivation system (CMS) was introduced by employing male-female team of workers at union council levels. and approach of the program was made broad-based by adopting a multi-sectoral and multi-dimensional strategy. In fact. participation in national conferences. increase in allocation of funds. expansion in service delivery infrastructure including mobile service units in the remote areas. major policies of the Sixth Plan were followed with emphasis on lowering fertility level. exception from budgetary cuts. Involvement of NGOs was streamlined by establishing National Trust for Population Welfare (NATPOW) with financial and operational autonomy. open motivational campaign. IUD and Injectable along with provision for maternal and child health services through program outlets. Field activities were provincialized. a major administrative reorganization was undertaken. In addition Divisional and Tehsil tiers were created to strengthen monitoring. association of the Private sector through the Social Marketing Program. experimentation of the village-based family planning workers scheme in eight districts of the four provinces. the program operated at a low key due to reorganization. Publications and give-away items were widely distributed. shift towards more effective contraceptive methods. political unrest and suspension of IEC activities. Both the schemes together have enhanced the coverage in the rural areas. group meetings. registered medical practitioners. The rural coverage increased by extending the scheme of VBFPWs to all the districts of Pakistan. From 1975-80. Studies undertaken by the Population Council and NIPS reveal that contraceptive prevalence have doubled in the villages where these workers have been deployed. hakeems and homoeopaths was envisaged. supervision and improve co-ordination at the implementation levels. Greater involvement of NGOs. the Ministry of Health also launched the Lady Health Workers Program of Primary Health Care and Family Planning.During 1970-75. During the Seventh Five-Year Plan period 1988-93. the breakthrough in the program occurred during the later part of this Plan (1988-93) with open and sustained political support. 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. 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. A special IEC program and quality service facilities were developed for large cities of the country. Parliamentary Group on Population and Development was constituted in the National Assembly wherein various resolutions were passed in support of the program. and awards for writing on population issues were institutionalized and implemented. In 1981.14-APR-03 . During the Eighth Plan Period 1993-1998. Simultaneously. Review of the program was made a regular feature at all levels. In order to elicit broad-based support from the public representative Standing Committees were set up in the Senate. In addition. such as sterilization.

The Chief Executive in his address on 11th July 2000 directed to achieve a population growth rate of 1. Therefore. In 2000.8 in 2000 is a big achievement. the population growth rate recorded a decline to 2. 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. Reduction of more than one child i.14-APR-03 . TFR of 5. The involvement of health outlets will help to decrease unmet need and increase the family planning coverage. 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. The Group recommended that all the health outlets should provide family planning services as part of their duties.. Later. The following table depicts the observed TFRs during the period.e. This shows a 2% percentage point increase per year. The decline in TFR indicates a reduction of 2 children from 1975 to 2000. is guided by the principle of building on positive elements of the on-going program.9 percent per annum by 2003 instead of 2. 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 impact assessment shows some progress on selected indicators such as CPR. The change in educational attainment by women. A broader reproductive health approach is being pursued with emphasis on mother and child health care. In accordance with the Chief Executive’s orders and the decisions of the Task Force reviewing the Population Welfare Program’s performance.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. rising age at marriage and desire not to have large families are important reasons for adoption of family planning in Pakistan. Similarly. The environment was changing fast in favor of realization of the need to moderate fertility to contain population growth rate. The current Ninth Five-Year Plan 1998-2003.4 in 1991 to TFR of new low level of 4. The scope and outreach of the program is being enlarged through enhanced and improved service delivery strategies with continued attention to rural areas.6 percent in 2002 while CBR touched a level of 29 births per 1000 of population in 2000. the merger of village based family planning workers and lady health workers was agreed to place under the Ministry of Health in September 2002. PAGE 52 O F 95 . once again the contraceptives were supplied to the Provincial Health Departments. which has shown an increase reaching 30 percent by 2000 from 12 percent in 1991. In view of the paradigm shift to reproductive health and family planning. it was proposed by the Review Committee to involve all health outlets to provide full range of family planning services. and predominant position of health infrastructure in terms of its vastness. Reduction in the fertility of younger age groups while looking at the age specific fertility rates is more pronounced in the following table. The declines in TFR during the last decade also documents the achievements of the Population Welfare Program. ensuring continuity and consolidation of the gains.

4. the overall vision for the health sector is based on “HealthFor-All” approach. One of these has been the Reproductive Health Package of 1999.27 5. 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. a quality of services.14-APR-03 . December 2001 PAGE 53 O F 95 . In addition the government has announced several policy statements on MCH and FP on various occasions. The new policy has three key features. unmet need for family planning remained high. 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. 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. Despite the recent sharp increase in contraceptive prevalence during the 1990s. and Federal Bureau of Statistics. joint efforts of private and public sectors.3 TFR 6. the period of 1990-2002 has seen the announcement of three health policies. involvement of partnership and with NGOs. The Population Policy aims at involvement of males in the decision-making of family size. Pakistan Demographic Survey 2000.8 Source: NIPS. for provision of service to remote and underserved areas. 48 National Health Policy 2001. efforts towards demand generation.Table 3. and regular monitoring and technical supervision. The latest is National Health Policy 2001. Pakistan Reproductive Health and Family Planning Survey 2000-01. 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 . increase in coverage and access to family planning services. human resource development.4 4. Agenda for Health Sector Reforms. religious hindrance. Age Specific Fertility Rates (ASFR). The proportion and level of unmet need for family planning is one of the highest in the developing countries. fear of side effects and health concerns. 1) health sectors investments as part of Government’s Poverty Alleviation Plan. b) Health policy framework In the health sector. which was a joint document of the Ministries of Health and Population Welfare. The factors that act as obstacles to the use of contraceptives are: husband’s disapproval.

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

IUDs and condoms. NIPS. Client satisfaction levels ranged between low to medium. and about 1. et al.000. MOPW operates 131 MSUs. injectables. 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. 2001. 3 – 5 clients per day) and that the staff lacked training in counseling skills. which provide RH services in remote rural areas. April 1998.688 have been established. PAGE 55 O F 95 . lack of coordination with community leaders and staff absenteeism. Population Council Working Paper Series No. 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”. A 1993 study of the functioning of FWCs52 found that the Centers were under-utilized (serving. the MSUs’ performance is quite satisfactory. About half of the clients visiting the RHS Centers came for contraceptive surgery and the remaining half to get other contraceptives. and are staffed. 2001 Hakim A. A National Institute of Population Studies (NIPS) study51 found that the clients were generally satisfied with the services provided at the RHS Centers. equipped and managed by the MOPW. The Ministry operates 275 RHS Centers for providing contraceptive services. Some of the other problems included frequent breakdown of vehicles.14-APR-03 . Type “B” RHS Centers (169 in number) are located inside selected government and private hospitals. “Situation analysis and users’ survey of Reproductive Health Services A Centers”. Cernada GP. FWCs are the most basic outlets for family planning and reproductive health services in urban and rural areas. there are 1300 male village based family planning workers for motivation and community mobilization. While their area of coverage is small. While the annual number of clients for contraceptive surgery steadily increased from 1993 to 2000. 53 54 Hakim A. 4. et al. Each MSU serves a population of about 30. Their main function is to provide temporary methods of contraception. The organization and performance of various facilities is described in some detail below. Managed and supervised by a Field Technical Officer (FTO). 50 51 Service statistics of MOPW. “Evaluation of Mobile Service Units. on the average. the Family Welfare Centers (FWCs) and the Mobile Services Units (MSUs). including the Reproductive Health Services Centers (RHSCs). 2001. through its provincial Population Welfare Departments (PWDs) provides services at its own facilities. each MSU is expected to organize 10-12 camps each month to provide curative care and family planning services.The MoPW. 52 Population Council: “A Study of the operations of the contraceptive logistic system of the Population Welfare Program”. NIPS Islamabad. et al. 1993. including pills. Besides. Population Welfare Program”. 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. although there were complaints about the high price of contraceptives provided by the MSU. A later study has found frequent stock-outs of contraceptive supplies at many Centers53. 21 percent of MSU had no proper arrangement for privacy.

and (4) lack of training of LHWs in delivery care and newborn care. Independent evaluations of the Program are generally positive. Finally. role of Ministry of Health is policy development. MNT special immunization activities. MoH designs National Programs/ projects in collaboration with provincial departments of health. coordination. 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. which are the remnants of the earlier experimentation of providing a national health system.14-APR-03 . while most peripheral facilities in the rural areas are underutilized. monitors and evaluates whereas the provincial departments of health and district health offices carry out the actual implementation of the Programs/ projects. National AIDS Control Program. National EPI Programme. Each year. Civil Dispensaries and Civil Hospitals. monitoring. the National Programme for FP and PHC is the most promising large-scale intervention of the MOH. Lack of female doctors and paramedical staff is another serious problem in all rural health facilities. Most staff members are unclear about their job description.3. MINISTRY OF HEALTH In the health sector. during 1990s. the Tehsil and District Hospitals provide specialized services and inpatient care. the concept of ‘National Programs’ materialized and proved to be successful. important initiatives of MOH are National Programme for FP & PHC (the LHWs’ Programme). 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. Clients expect free consultation and free medicines. In addition. In reproductive health. health facilities bearing various other titles also exist. The only preventive services provided at the primary health facilities are maternal and child health care and immunization. The Programme is exclusively an attempt to provide basic RH services and information to women at their doorstep. (2) Services are limited in health facilities to which patients are referred. the MOH/DOH owns and operates the largest number of tertiary care hospitals in the country. National Nutrition Project and Reproductive Health Project Since independence in 1947. some preventive services and referral to the next levels of care. Teaching hospitals are usually over-crowded. The patient-load on public health facilities varies greatly. evaluation and research. regardless of their level. depending upon the nature of services provided. arranges necessary funds. In practical terms. 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. The primary aim of the health facilities under the MOH/DOH is the provision of curative care. such as: Sub-health Centers. However. These hospitals are located in the major urban centers and are usually attached to medical colleges or other post-graduate medical institutions. Services are provided either free of cost. or at minimal charges. few weaknesses of the Program include: (1) LHWs are seriously undersupplied with drugs and contraceptives. Additionally. PAGE 56 O F 95 . (3) Need to increase effectiveness of supervision. At the community level. provide technical assistance. also transport for supervisors. 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. At the primary level. Women Health Project. 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. collaboration with International agencies and provision of services through federal health institutions. all primary health facilities mainly provide outpatient curative care. under-staffed and under-funded. Virtually all clinical staff members are involved in some kind of private practice.

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

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

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

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

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

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

PAGE 63 O F 95 . (Source . The Armed Forces of Pakistan. Large for-profit commercial hospitals located in big cities provide high quality care to those who can afford their services. Technical Assistance for these activities was provided by ILO. Fauji Foundation. The LHW-HMIS is a parallel system and is not a part of the HMIS. Steel Mills. PRIVATE HEALTH CARE Pakistan’s private health care delivery system. those inputs were limited to the central warehouse in Karachi and the federal administration in Islamabad. However. However. WAPDA. 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. typically serving the poorer segments of population. Pakistan Intl. comprising inadequately trained or untrained providers (generally referred to as ‘quacks’) also exists. The focus of earlier UNFPA support was on improving the knowledge of workers related Family Planning and the adoption of a small family norms. A total 450 health service outlets were involved in delivery of Family Planning services for their employees. is just beginning to participate in the efforts to improve the reproductive health status in the country. B . The quality of care and scope of health services provided by the private sector vary greatly between urban and rural areas. PRIVATE SECTOR 1. ORGANIZED PUBLIC AND PRIVATE SECTOR The involvement of large public and private sector organization for the promotion of reproductive health and family planning dates back to the 80s. the data from the LHWs MIS is more reliable because of the monitoring and supervision system of the National Programme.The National Programme for FP/PHC established an MIS for the Lady Health Workers in 1994. the system collects information on the services provided by the LHWs including information on the community served by the LHWs. On the other extreme are the small clinics and health centers run by general practitioners trained in basic medical care. While no systematic evaluation of past experiences with the TGIs was conducted.14-APR-03 . Pakistan Telecommunication & Postal Services. Assistance to these large industrial organizations was channeled through the Directorate of Workers Education of the Ministry of Labour and Manpower. 2. The institutions comprised 14 major public sector organizations employing a workforce of one million e. 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. existing information does not support any significant contribution to either of the three reasons stated above. A large informal sector.NIPS Assessment). Airline and Agricultural Development Bank.g. UNFPA as part of its sixth country programme is providing support towards development of a common system for the MOH. accounting for about 60 percent of the total health expenditures. UNFPA through its Sixth Country Program has provided additional inputs and technical assistance including a mapping initiative for the MOH and MOPW facilities. Recently. This system was further developed with the assistance of UNFPA between 1994 and 1998 through the provision of computer equipment and training.

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

It is interesting to note that. providing over 20 percent in CYP and distributing over 58 percent of all condoms. DFID and Population Services International (Washington D. 9. The two social marketing firms maintain a combined network of 12. b) Linkages with public sector Private sector. especially for-profit. while GSM sells condoms and oral pills at subsidized prices through an incentive program to thousands of retailers around Pakistan. the health managers mostly do 61 Pakistan Nursing Council Act. ISSUES a) Regulatory issues There are no explicit or effective regulatory mechanisms or laws governing the provision of health services by the private sector.61 However. which raises serious ethical issues and further deteriorates the quality of care in the public hospitals. Key Social Marketing (KSM). SMP manages the largest FP/RH operation in the private sector. the extent of implementation of these few regulatory mechanism is also a matter of concern. 7. 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. LHV and midwives. It is common to redirect patients from public hospitals to private clinics. 1973 PAGE 65 O F 95 . it is also empowered to impose fine and rescind the licence of workers involved in mal-practice. Neither has there been any comprehensive national study done on the private health facilities and services. Lack of data in this area is also one of the reason for not having required regulatory mechanisms in place. Apart from registration of the above category of workers. The other organization. while one requires a license to establish and run a pharmacy or medical store. 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.14-APR-03 .562 chemists and 47.100 paramedics. is also not playing its role in regulating the practices of its members.C). Pakistan Medical Association.400 doctors. the largest and most influential professional organization of medical doctors in Pakistan. no such permission is required by a fresh medical graduate to run a private clinic or maternity home.500 retailers.by KfW. However. A proposal for Ombudsman was conceived but still it is on papers only. It is the second largest provider of family planning and RH services in Pakistan after the Government. At the district level. sector has grown much faster than the not for profit sector and mainly without any support from the government. 5. 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. A significant number of public sector medical care providers double as private practitioners in the evening. Pakistan Nursing Council is the regulatory body for the nurses. The Pakistan Medical and Dental Council (PMDC) is not a regulatory body and its role is mostly limited to registering medical graduates. solely supported by DFID is making its contribution by supporting local manufacturing initiative for pills.

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

Various surveys suggest that awareness about issues such as maternal and child health. While decision making about availing healthcare facilities is usually the prerogative of the males. They are only called when the matters get out of control of the supervising Dai. the foremost imperative action is referral for seeking essential obstetric care and neonatal services from the appropriate place. the knowledge about danger signs of pregnancies and emergency obstetric care is also not very high even in urban areas. Male members are generally not involved at the time of the delivery as females take care of the whole process. affordability and quality of services. Besides many reasons revolving around quality of care. Maternal and infant mortality is unacceptably high in Pakistan and continues to pose challenges for public health professionals and planners. In the context of devolution and decentralization initiative of the government. child birth and reproductive health issues. should include intensive IEC and advocacy campaigns for men besides effective awareness programs for women and families. The large umbrella organizations which are mandated to build the capacity of small NGOs in accessing fund. Whereas the awareness about maternal and child healthcare and family planning is low in rural areas. 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. STIs and STDs is low in Pakistan. For decreasing maternal and infant mortality. correct use of family planning methods. therefore. to shift the women to a hospital. Simultaneously the need to fund the large NGOs like social marketing which have substantial contribution in the reproductive health sector should not be ignored.000 infants fail to reach their first birthday ( PRHFPS 2000-01). perhaps the way forward is enhanced cooperation between the government and social marketing.000 women die due to pregnancy related cause and about 360. CBOs and other non-profit organizations. accessibility. 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. gender. AN UNDERUTILIZED PUBLIC SECTORS As mentioned earlier. PAGE 67 O F 95 . RHCs and FWCs. Considering the public-private concept of cooperation between the government and private sector. poor health seeking behavior of people is also a contributor in the low demand and utilization of services. Interventions in safe motherhood. providing services and organization have not been very successful leaving the small NGOs to fend for themselves. are under utilized in Pakistan. III. the facilities of the public sector are underutilized for various reasons including availability. LACK OF AWARENESS WITHIN THE COMMUNITY As has been pointed out earlier.14-APR-03 . AN INSUFFICIENT DEMAND FOR SERVICES A .their own sources. most of the peripheral health facilities including BHUs. B . men are not fully aware of their role in the management of emergency obstetric care. communicable disease. 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.

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

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

and their active involvement in safe motherhood interventions. are associated with high utilization of obstetric care services by women. Additionally. As husbands and fathers. there are large gaps in our knowledge of the prevalence and determinants of men’s reproductive illnesses.14-APR-03 . fake herbalists and quacks in the urban and rural areas of Pakistan. sexually transmitted infections and cancers of the male reproductive tract. The focus on men’s involvement in reproductive health is most marked in family planning. Several studies are available that document increased effectiveness of family planning programs when men are included in the interventions. supplies and follow-up services just as women do. Nigeria and India have found that husbands’ knowledge of obstetric danger signs. and counseling regarding the all-too-common problems like erectile dysfunction syndrome. These materials have been successfully tested in varied urban and rural settings. Research in these areas would guide policymakers in developing effective strategies to address men’s reproductive health needs. In summary. 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. there is a need to address each of the three aspects of the reproductive health issues related with men. they also play a role in determining the dietary habits of pregnant and lactating wives as well as their young or adolescent daughters. particularly prenatal care. and understanding is also lacking on why an overwhelming majority of men visit informal health care providers for sexual and psychosocial disorders. Worldwide. education and counseling materials on family planning and safe motherhood that are exclusively designed for use by husbands. n n PAGE 70 O F 95 . However. Further research is required to establish the most cost-effective methods for involving men in women’s health interventions. leading NGOs including Family Planning Association of Pakistan. National Population Welfare Program included male (FWAs) to cater to the information needs of the male population of their communities. several studies have shown that involving men in the family planning programs has a positive impact on contraceptive use. educating them about the dangers of these complications could greatly facilitate women’s timely transfer to a hospital in emergencies. including sexual education before marriage. Operations research is also required on how to train and motivate lady health workers for couple counseling. 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. In Pakistan. The Asia Foundation and Marie Stopes Society have developed information. as follows: n Men as Clients of the Health Care Delivery System: Men have their own reproductive health needs. Since husbands are key decision-makers when it comes to seeking medical care for obstetric complications. The ‘continued motivation system’ introduced in the earlier days of the Population Welfare Program in Pakistan depended significantly on male motivators. Men as Clients of the Population Welfare Program: Men need advice. Men as Decision-makers: Husbands play an important role in decision-making with regard to obtaining health care for women. choice of birth attendant. Research studies in Bolivia.the men seeking advice and treatment for their sexual and psychological problems who contribute in large part to the booming businesses of faith healers.

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

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. This would foster for a district strategy enabling the managers to decentralize authority and responsibility together. suppression of administrative malaise in timely recruitment. 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. A) Political Leadership: Under the devolution plan. Government of Pakistan. 2.14-APR-03 . the performance of district managers is limited by their capacity to prepare district plans. decentralization of administrative authority. The devolution plan has major implications for all the social sectors including health. use information for improved decision. The district is the basic administrative unit in Pakistan. and effectively function as a coherent management team. PAGE 72 O F 95 .devolution plan makes the line departments responsible to and accountable directly to the communities they serve. involve communities. and a paradigm shift in the minds of the government functionaries to be accountable to the communities they serve. sensitization of the local political leaders about the importance of social sector concerns. The districts are uniquely placed at the level where they are in a position to maintain a vertical relationship with higher management levels. lack knowledge and skills in the planning and management of social services in the public sector. education and population. However. diffusion of the power authority nexus and distribution of resources to the district level. Chief Executive Secretariat. There are several prerequisites for the success of the devolution process . 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. efficient and equitable. user friendly rules and procedures. serving on the district and union councils. The proposed plan was based on five fundamentals:67 devolution of political power. 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.clear redistribution of provincial and district authority and responsibilities. de-concentration of management functions. provide supportive supervision. for effective delivery of services. 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. and ensuring community participation for better utilization of social sector services. 2001. 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. horizontal relationship with other local departments and external relationship with communities and organizations they serve. National Reconstruction Bureau. capacity development of the district managers. a problem area is that the newly-elected local representatives. 67 Local Government Plan 2000. August 2000. enhance funding and their timely utilization and effective monitoring and supervision system to ensure availability of quality services and material.

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

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

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 1996-97.6 percent per annum but the trend has become erratic in recent years. as it did in 1992/3 when it was a mere 2. III. 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. Despite an overall impressive economic growth record. One of the major reasons for little progress in the social sector has been the low level of resource allocation.04% in 1999-2000. and other years when it fell to less than even half.In line with the Government policy of decentralization and devolution. The figure in Table 4. Further. The transferred employees of the Population Welfare Programme have become provincial civil servants under full administrative control of the provinces. but dropped drastically to 0. 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.14-APR-03 . 6. Social development in Pakistan has been subject to various constraining factors.552 in 1998. 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.1 compares social sector expenditures with the overall public expenditures (Rs.2% against the overall public sector expenditure from both development and non-development budget. This rose to 19% in 1998-99.27 percent. Throughout this period there had been a regular trend of increase in the overall public expenditure. but thereafter the trend became erratic. It shows that the ratio of social sector expenditure remained only at 8. The increase between 1996-97 and 1997-98 was 6% only. Pakistan’s progress in the social sector has been unimpressive. has increased from 0. PAGE 75 O F 95 . of which some are generic while others are sectoral.8 billion) during the last decade (financial years 1990-91 to 1999-2000). This situation indicates that the expenditure on social sectors has not increased in proportion with the general increase in public expenditure.655.343 in 1975 to 0. on the average it was around 5. There have been years when the rate rose higher than the average rate. The current Human Development Index (HDI) for Pakistan. Field activities too have been transferred to the provinces under an Ordinance issued in 2000.

Exp.1991. Public exp. 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. Public Exp. high costs and poor maintenance. Draft Poverty Assessment for Pakistan. Dev. Highly centralized administrative and financial systems which are resulting in resource leakage. 200 0 Source: ADB. As % of total exp.1998. which is resulting in poor targeting. April 2001.14-APR-03 . 1990. Exp. Some of the factors responsible for this inequity are as follows: • • Failure to involve the local community in project design and implementation. imprecise job descriptions and inadequate training plans for human resource development. 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.1994. 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.Figure 4. Non-observance of the policy of merit and transparency in recruitment.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.199991 92 93 94 95 96 97 98 99 00 Total Expenses Social Sect. Interest Domestic Interest Foreign Social Sect. Funds being insufficient in the first instance are irrationally used more on brick and mortar and salary rather than on service delivery and quality.1996. 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 . • • IV.1997.1995.1992.1993.

were incorporated to provide a more comprehensive Reproductive Health Services Package. Options.933 88. other elements of reproductive health. A noticeable change was observed in the Eighth Plan. which indicates that the Government of Pakistan remains sensitive towards its population issues and was ready to allocate more resources for addressing the complex issue despite unfavourable economic conditions.039 7.3 *67 Source: ADB TA-3387. Reproductive Health Project-Pakistan. The increase in allocations continued in the current 9th Five-year Plan.3. 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.The population programme of Pakistan is predominantly funded by the GoP and international assistance.14-APR-03 .08 to 1. However the change has been quite gradual. As can be seen in Table 4.300 3.1 *66.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 1.2 shows that except for the initial three Plans.340 1.9 86.654 *10. PAGE 77 O F 95 . especially in the current 9th Five-Year Plan.8 74 6th (1983-88) 7th (1988-93) 8th (1993-98) 9th (1998-03) * Upto November 2002.5 100 77.039 5. Table-4. 2. public expenditure on the population welfare programme in Pakistan had initially been extremely modest.0 (1970-78) 5th (1978-83) 1. in which the allocation increased by more than 157% over preceding plan allocations. Until the 7th Five-year Plan.01 percent of the overall macro plan size. allocations remained between the range of 0.2: Ministry of Population Welfare Allocations and Expenditure (Rs. Table 4.100 15.535 9.0 84. and it fluctuated in response to the variations in programme strategies and in political commitment. The expenditure trend (Table 4. the overall implementation of the social-sector related programmes remained weak and allocated resources could not be fully utilized. in million) % of Actual Plan ADP Actual % of ADP to Exp. 45. in the later y ears.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.914 *6. when the allocation for population programme was substantially low.625 2. as defined in the ICPD Program of Action. thereafter while there were relative increases in the social sectors.184 3.029 834 103.2 82. Datalines. 2000.9 81.800 824 9 617.686 3. As explained in Chapter 3.

8 46.1% 4.4: Table 4.million) Total Allocation (Rs.8 7.8 62.8 22.4% 84.6 1.8% 100% *Includes antenatal care.7 0.3 6. PAGE 78 O F 95 . 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.6 0.9% 92.Table 4.3 21.3 1.4 1. under the UNFPA’s Resource Flows for Population Project.144.1% 42.6 0 2.200.9 2.920.401.1 11 Construction 2.5 1.1 38. tetanus toxoid vaccination.8% 5. 1.9 22.7 Training 8 9.4 16.4: Cost Share of Preventive & Curative Services by Type of Facility BHU EPI MCh* Total Preventive Total Curative Total Facility Cost 25.6% 100% THQ 5.8 15 14.4 1.9 5 5. and family planning Source: World Bank.256.172. funding from international resources increased by about 18% in fiscal 1998-99 over the ratio in the fiscal year 1997-98. is not being reported separately.133 1.6 94.181.6% 7.9 1.9% 100% RHC 9.4 1.1% 100% DHQ 3.2 1.9 2.4 62.3% 2.000 1.7 1.2% 95.8 Services IEC Programme 11.5 98.1% 57.4 19 17 4.1% 1.17 70 (%) Source: Ministry of Population Welfare 1999-00 15. as an integral part of total health expenditures. has been collecting data about Pakistan’s resource flows to its population sector for the last few years.2 1.0% 17.3 55. 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. Pakistan: Towards a Health Sector Strategy The Netherlands Interdisciplinary Demographic Institute (NIDI).4 5.2 1.14-APR-03 .8 3. growth monitoring.2 11. A World Bank study attempted to give a break down of the total cost of various health facilities.2 31.100 1.3: 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 20. However.2 Research 2.7 4.4 82.7 Expenditure on reproductive health.9 Organisation Population Welfare 46.433 2. Brief details are reproduced in Table 4. 1998.1 23.000 million) Expenditure/Allocation 64.7 1 Total Expenditure 710.4 Logistics and Supplies 2.2 44.194.6 (Rs.1 36.2 2 2 2.3 45.6% 15.

5 23% 77% Percentage Going To: Ministry of Population Welfare Ministry of Health Ministry of Women Dev. is faced with widespread poverty. which is 13. Table-4.2% 24. Pakistan.3% 26.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 external debt burden was US$36.24% 26.887.6% 279 92. Pakistan cannot be expected to meet its essential targets without the availability of external financial assistance.934 28% 72% 1999-00 4.8% 4.14-APR-03 . [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.3% 0.7% 76.6 indicates that assistance in this sector from the PAGE 79 O F 95 .5% 7. Population planning is an important component of the social sector that is very closely related with poverty.5 23.8% 26.1% V.8% 0.7% 0. as with many other developing countries.6% 50.5% 0.4% 23.6% 216 95.5 billion.5% 22% 529 91.998. the country paid $1.1% 0. Ministry of Education Ministry of Labor & Manpower Provincial Health Departments Total Budget NGOs From international Resources From Self generated Income 50% 22.247 26% 74% 3.9% 8. At the end of 2002.1% 51.3% 0.96 billion in debt servicing.4% 17.3% 1998-99 3. one of the limiting factors is the resource crunch.] For undertaking the plans that focus on poverty alleviation. Given this situation.8% of its overall foreign exchange earnings.2% 49.7% 0. In the fiscal year 2000-2001.1% 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 3.01% 0.6% 546 82.13% 0.5% 0. THE ROLE OF EXTERNAL ASSISTANCE IN FINANCING THE POPULATION AND REPRODUCTIVE HEALTH PROGRAMME. A review of the Table 4.

except for the year 1994 when the bilateral funding was only 37%.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. SAP-II. The 1994 ICPD’s Programme of Action estimated that in the developing countries and the countries with economies in transition.761 33. USA. PAGE 80 O F 95 .6: Donor funds for population Year Total $ in 000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 15. World Bank/IDA.6. the main international donors for population activities were UNFPA. By the year 2000. the costs of the implementation of reproductive health programmes. UNFPA is among the main donors for Pakistan’s population sector. As can be seen from Table 4. Financial Resource Flows for Population Activities in 1999. The international donor community has shown its commitment to achieve the goals and objectives of the conference. and there is an increasing flow of resources in the form of international assistance for population activities. the Asian Development Bank.670 15. Approximately two-thirds of the projected costs in developing countries will have to come from the international donor community. will cost $17 billion by the year 2000. as well as programmes that address the collection and analysis of population data.967 28. Bilateral assistance has been the main channel. Note that the NGO share actually reflects additional donor resources as most NGOs are donor dependent.028 12. Table-4. donor funding for population activities in Pakistan has fluctuated. New York.14-APR-03 .519 14. including those related to family planning.508 15.771 15.international community continued at a reasonable level during the last decade despite an adverse political climate.092 18. maternal health and the prevention of sexually-transmitted diseases.561 28.

788.000 1995 5.000 2. however.000. The All Pakistan Women Association (APWA) was t e first organisation and was founded in 1949.711.000 1998 5.000.000 1996 6.000. It also envisages the PAGE 81 O F 95 .000 4.111 VI.111 37. The Asia Foundation. around 16. the Marie Stopes Society (MSS) and the Family Planning Association of Pakistan. Islamabad (1994-2002) in US$ Total Expenditure 3.000 3. Save the Children (US).000. Two types of NGOs are active in Pakistan: (a) international NGOs . A glance through Table 4.000 2001 7. by taking a lead role in coordinating the implementation of a multisectoral programme. Some of the international NGOs are the Pakistani affiliates of their international offices like Marie Stopes Society.000 600. 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.000.400. They tend to be dependent on funding from international sources.500. The absorptive capacity of local NGOs is relatively low and constrained by the overall lack of funds.000 1997 5. and (b) national NGOs.000 6.000 4. have shown their potential to work in difficult sociopolitical conditions with a measure of success in achieving their objectives.7: UNFPA Expenditure Trend Year Program Regular 1994 4.888.500.000 4. The political environment in Pakistan is not congenial for local NGOs.000 3.600.200. Most of these NGOs implement their own social sector/population programmes for which funding is largely by international donors.100. According to an estimate. the NGO sector was almost non-existent at the time of independence. Few examples are the Pakistan Association for Voluntary Health and Nutrition Activities (PAVHNA).111.000.000 Average 94-02 5. NGOS’ AND PRIVATE SECTOR’S ROLE IN FINANCING OF POPULATION AND REPRODUCTIVE HEALTH ACTIVITIES In Pakistan. and the Population Council.889 Source: UNFPA-Pakistan. a majority at the district level. (See Chapter 3).14-APR-03 . The role of national NGOs in Pakistan has remained limited due to several reasons including those related to national security.000.000 2002 7. Some of these NGOs have. Efforts were made in the past to organise local NGOs for increasing their role in the social sector but there have been constraints.400.889 Total estimated 57.Table 4.000 1999 5.000.000 2000 7.000 NGOs are currently working in Pakistan.600. The h number of NGOs has steadily grown over time and rapidly expanded during the last two decades.000 4.600.86 reveals that most of the time 85% to 90% funding has come from international donors. VII.

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

their domestic policy objectives have now changed substantially.7 2. Establishment of a clear policy of shared inter-ministerial responsibility for implementation of population sector plans.5 0.3 93. with ongoing efforts to forge common definitions. their policies impacted significantly and positively on resource flows for population activities in the immediate post-ICPD period. Financial Resource Flows for Population Activities in1999.2 3. While the allocations of the international donor community funds encouraged a commitment of signatory countries to achieve ICPD objectives.1 1. Table 4. implementation.6 31.9: 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 15.0 4.9 21.0 12.8 65.6 1.1 2.1 1.5 16. 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.8 33.10 above.9 2.1 57.6 2. and funding under the Social Action Programme.3 2.0 28.4 60.8 Source: UNFPA. Table 4.6 89. 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.1 74.8 2.7 1.6 39.4 87.6 58.7 1.6 45. 1999.9 25.0 2.6 75.6 100.2 3. Producing working definitions of reproductive health in both the Health and Population Welfare ministries. PAGE 83 O F 95 .9 33.14-APR-03 .2 44.6 28.2 14.8 15. and Promulgation of a national plan of action for the empowerment of women.1 87.9 1.8 3.1 18.• • • • • Incorporation of major elements regarding social sector planning.

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. with the decision-making and authority under this set-up be made closer to the people.IX. DEVOLUTION OF AUTHOR ITY The GoP introduced the Devolution Plan which restructured the district governments with a view to enhancing the participatory roles in planning and decision-making at the grassroots level. Concurrently it poses new risks and challenges also. byelaws. 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. PAGE 84 O F 95 .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.

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

A . NATIONAL ADVOCACY AND COMMUNICATION STRATEGY 1. the transition could be jeopardized. the national health policy 2001 entitle “The way forward. ADJUSTING EXISTING POLICIES 1. there is a need to bridge some gaps and orchestrate its implementation. The Human development section of PRSP should look at fertility reduction as a first priority. Similarly. The following suggestions try to address both.uncertainty about the ability to sustain the trend. Adjustments in policies and reorientation of advocacy efforts to safeguard this transition are necessary. These efforts have been effective as is evident from findings of various household surveys. the Population Welfare Programme has always maintained a communication campaign to support its service delivery efforts. However. B . Such a policy could at its core rest upon a structured and mutually supportive partnership of public and NGO sector. the population policy of Pakistan (July 2002). These documents elaborated by the Government of Pakistan constitute a remarkable and very comprehensive policy framework for the social sector. The development of a comprehensive national maternal health policy should be pursued together with a set of national intervention guidelines to reduce maternal mortality and morbidity. In view of the social cultural and religious constraints this is no mean achievement. and the national policy on education. agenda for health sector reform”. 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. There is evidence to suggest that with growth in contraceptive use tapering off. Awareness regarding family planning methods has been consistently rising since 1991 and is almost universal according to PRHFPS 2000-01. to ensure that investments in other areas are not constantly undermined by an uncontrolled demand. Considering that people under 2 years of age constitute 63% per cent of the population. PAGE 86 O F 95 . 2.14-APR-03 . the national plan of action for women. people have been made aware of family planning choices through field workers. a 5 comprehensive youth and adolescent health/reproductive health policy is urgently required. ACHIEVEMENTS In the public sector. 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. Past IEC campaigns have been relying on mass media for creating awareness and have also focused on increasing visibility of the sources of services.

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

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

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

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

Pakistan Fertility and Family Planning Survey. ACHIEVEMENTS Aiming for a better understanding of population and development calls for strengthened capacity in population and RH data collection and dissemination. 1991.14-APR-03 . Here. inducting new on a permanent basis. Such a centre could have exchange of researchers. Among the numerous reports. Creation of an in-country academic centre of excellence for training of population specialists is required. Attitude and Practices. Pakistan Demographic and Health Survey. This organization. These include Pakistan Institute of Development Economic. 1987. Follow up and monitoring of ICPD indicators could build on the valuable experiences of the National Institute of Population Studies (NIPS). PAGE 91 O F 95 . which is being merged with FBS. should be strengthened personnel-wise with a defined agenda for the inter-censal period. Of late. several independent consultants have come forward in the RH field. 2001. over the years. 2. though sporadically. and Pakistan Reproductive Health and Family Planning Survey. with various international demographic research institutes. At the same time. These studies are widely quoted by the researchers. 2002. surveys and researches has been significant. KNOWING BETTER A . Population Cells in some of the universities where demographic research is carried out. and. recognition may also be made of other agencies and persons in the area. PCO is short of trained staff and the existing personnel are not always abreast with the modern data collection and analysis techniques. and twinning arrangements. they have carried out studies and researches after having been commissioned by various international and donor agencies. NIPS’s contribution in carrying out various studies. The Agha Khan University. and Reproductive Health of Youth: Perceptions. NIPS. Pakistan Census Organization conducts decennial census every ten years with a long slack period in between.V. has had its professionals trained abroad but has seen attrition too as several of them have left for better opportunities. There is a lack of expertise in population in the country. raising its expertise at international level. RECOMMENDATIONS The capacity of the National Institute for Population Studies should be further enhanced by training the existing personnel. 2002 (118 individual reports). 1998. ENHANCING NATIONAL EXPERTISE 1. mention may be made of The State of Pakistan’s Population. Currently two reports are in the final stages: District Profiles of Pakistan and AJK.

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

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

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

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