By the end of the session, participants will be able to: Define Family Planning (FP) and related terms.

. Briefly describe how Family Planning contributes to the MDGs. Describe the evolution of Family Planning interventions from 1947 to present. Illustrate vital trends (situational analysis) in health indicators related to Family Planning.
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Continued Discuss the role of funding agencies, public sector, and private sector in implementation. Sensitize the unmet needs of vulnerable population. List the program shortcomings in Pakistan. List a few recommendations for health reforms. Illustrate one key paper.
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FAMILY PLANNING Definition

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

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

MDG 1: Eradicate Extreme Poverty and Hunger MDG 2: Achieve Universal Primary Education

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BACKGROUND

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FERTILITY DECLINE
At the inception of population program Pakistans fertility decline rate (6.6 births per woman) was between Indias (5.9) and Irans (7) but experienced fertility decline the slowest in the region (1990s). Pakistans total fertility rate (TFR) is one birth more than India and Bangladesh and two births more than Irans TFR. With current TFR rate Pakistan is set to reach the proposed 2020 goals ten years even later.
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FERTILITY REGULATION
Contraceptive Prevalence: Contraceptive Prevalence rates in Pakistan remained relatively below 10 % during the seventies but increased significantly by 1990s to almost 28 %. CPR increased from 21 % in 1991 to 49 % in 2007 amongst married women. Use of contraceptives in rural areas has increased over the past two decades still lacks behind significantly.
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FERTILITY REGULATION
The Contraceptive Prevalence Rate (CPR) is 30% in Pakistan a figure that has virtually remained the same over the last decade which is considerably low as compared to other Muslim countries. Iran has 74 % CPR, Turkey 71%, Morocco 63%, Indonesia 61%, Egypt 60%, Bangladesh 56% and Malaysia, 55%.
SOURCE: Sadiah Ahsan Pal. Family planning: Pakistan still has a long way to go.
http://tribune.com.pk/story/442532/family-planning-pakistan-still-has-a-long-wayto-go/ (accessed 5th November 2012).

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

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FERTILITY REGULATION

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

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UNMET NEED
In 1991, 40% women wanted to limit childbearing, in 2007 it increased to 52%. Although more than 50 percent of women wish to limit childbearing and around 20 percent wish to space their next birth, only 30 percent are using contraception, indicating unmet needs. The proportion of recent births that are unplanned rose from 21 percent in 1990-91 to 24 percent in 2006-07 which lead to potentially unsafe abortions. These problems are even intense in rural areas.
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UNMET NEED
Rahnuma-FPAP President Mehtab Akbar Rashdi said that London Summit will be the largest family planning event where 69 poorest countries with HIGHEST UNMET NEED of family planning will participate. Unfortunately, Pakistan is one of them.
SOURCE: Myra Imran. Pakistan has worst family planning indicators in the region. http://www.thenews.com.pk/Todays-News-6-112757-Pakistanhas-worst-family-planning-indicators-in-the-region (accessed 5th November 2012).
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UNMET NEED
Out of those women who opt against contraception, 28% choose to do so by leaving it to God. This reason is closely followed by opposition from husbands; fear of side-effects; and lack of knowledge. Only 5% have a perceived religious prohibition.
SOURCE: Sadiah Ahsan Pal. Family planning: Pakistan still has a long way to go.

http://tribune.com.pk/story/442532/family-planning-pakistan-still-has-along-way-to-go/ (accessed 5th November 2012).

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Vulnerable Group POOR!

Fertility rates in Pakistan vary by womens education and household wealth status. Women across all wealth circles desired for lesser childbearing in 2007 than 1991, but richer women used contraceptives much more to prevent such cases. This gap of contraception usage has raised alarmingly between women of different wealth status over the past decade. Unmet needs during 1991 stood better for poor women but lack of contraceptive usage in comparison of desire to limit childbearing takes it to 30% while unmet needs of richer women are practically nonexistent.
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LACK OF ACCESS
Access to FP services in Pakistan varies from urban to rural areas. It takes 40 minutes on average to reach a RH facility in urban areas while it takes 96 minutes in rural areas. (1991 DHS) Distressingly, the amount of poor population in rural areas is far higher causing lack of contraceptive usage and superfluous childbearing.

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QUALITY OF SERVICES
Quality of FP services remains a huge block in the path of applying population policies. It is found that over time increasing numbers of women have reported fear of side effects and health concerns as their primary reason for not intending to use contraception in the future both in urban and rural areas.
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The National Programme for Family Planning & Primary Health Care
Also known as the Lady Health Workers Programme (LHWP) was launched in 1994 by the Government of Pakistan. The Lady Health Worker Model: employment of over 100,000 Lady Health Workers (LHWs). Recruitment and trainings: First Level of Care Facility (FLCF). Scope of work: 1 LHW = 1000 person/150 homes. Supervision and monitoring: Lady Health Supervisors and Field Program Officers.
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The National Programme for Family Planning & Primary Health Care
4th third party evaluation: LHWs play a substantial role in preventive and promotive care and in delivering some of the basic curative care in their communities, as well as providing a link to emergency and referral care. It also concluded that LHW Programme has significant impact on the population it serves and it has maintained the impact despite significant expansion of the Programme (Oxford Policy Management: 2009)
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CURRENT SITUATION

CONTRACEPTIVE PROCUREMENT
Directorate of Procurement Material and Equipment (PME). Expected to increase from reported 8.4 million in 2008-09 to 10.8 million in 2014-15. Dependant on international funds. Local manufacturing of pills and injectables is already underway and feasibility studies are under consideration for establishing IUD/CU-T manufacturing units in Pakistan.
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FUNDING STREAMS
Funds were primarily produced by Federal government and then distributed to provinces. Shift in international funds from FP to RH in 1990s and to HIV/AIDS recently has damaged the progress of the FP program. Major funding is provided by KFW, UNFPA and USAID. Bulk of these funds are used in social marketing acquiring contraceptives.
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PUBLIC PRIVATE PARTNERSHIPS

Social Marketing NGOs and CBOs Public-Private Sector Organizations (PPSOs)/Target Group Institutions (TGIs)

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CURRENT SOCIO-ECONOMIC FACTORS

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

Low Participation of Women in Society: male dominated society impedes women to use FP services. RH and FP Survey 2003, one in three women was not allowed to leave her home alone and 42% of women who were able to go to health centers on their own were using contraception compared to half that proportion. 21%, who were not allowed to go to these facilities at all. Pakistan has the highest gender gap in labor force: women employment (19% from 13%).
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PROGRAM SHORTCOMINGS
The Population Policy (2002) was strong in principles but frail in application. No Proper planning before starting new programs. Instead of introducing new programs and addressing latest issues only old plans were reinforced. Expansion of FP services remained restricted to urban areas. Use of contraceptives remained confined to urban areas through organizations such as Key and Greenstar Social Marketing. Lack of Understanding of Population Issues: Politicians, bureaucrats and other organizations have rarely considered population a huge issue. Other public-officials hesitate from even discussing it due to religious pressures. Provinces often support population growth to get handed with government awards and aid.
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RECOMMENDATIONS

FEMALE EDUCATION
Without making education accessible to all corners of the society; particularly women CPR of global standards cant be achieved in the long run. Women education can lead to Pakistans transformation from agrarian society to an industrialized base where gender roles, abilities and powers will be worked more imperatively leading to better implementation of FP policies and RH services.
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ROLE OF STAKEHOLDERS
The economic and finance partners, including the Ministry of Finance who need to understand that economic growth is directly proportional to better FP services. The health partners: Improving FP and RH services by working together and putting organizational efforts would further help private and public providers of health services in their own goals. International Community and Donors need to emphasize on FP services along with other medical aids as it can help reducing those medical issues in the future. Furthermore, they must use this opportunity to help Pakistan when it eagerly wants to improve its FP record. 2/3/2013 34

OWNERSHIP TO STRENGTHEN PROGRAM

GOVERNANCE: FP services in Pakistan can only improve if responsibilities are fully owned by people, organizations and authorities. SERVICE DELIVERY of family planning services at all health outlets; with population welfare outlets playing a complementary and specialized role. COORDINATION: Strong body to steer, assist and coordinate the role of the private and not-for-profit sector. ACCESS & EQUITY: Maximum number of NGOs and CBOs providing services in areas where underprivileged, hard to reach populations are located. Strong MONITORING and oversight role at the center but with full participation of provinces.
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KEY PAPER
Karen Hardee, Elizabeth Leahy. Population, Fertility, and Family Planning in Pakistan: A Program in Stagnation. Population Action International.October 2008;3(3)

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

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