Imagine you’re a woman living in Pakistan who would like to decide if and when to have children. You’re going to school, or you’ve got a job, or you’ve had a child and simply want some space before your next pregnancy. How easy will it be for you to get your needs met?
That question is harder to answer than you might think.
Last month, we examined Pakistan’s key demographic indicators, finding that increased access to voluntary family planning is key for realizing the country’s potential demographic dividend. But is Pakistan really making progress toward improving access to family planning information, services and supplies?
Pakistan was one of the first South Asian countries to initiate a family planning program (1960), though their efforts floundered until the 1990s, when outreach activities by female community health workers brought services and information to people’s doorsteps. Between 1990 and 2001, contraceptive prevalence increased sharply, from 12 to 28 percent, though progress has slowed significantly since. Pakistan’s family planning activities, which were divided between the Ministry of Health and the Ministry of Population Welfare, suffered from a lack of interdepartmental coordination, inefficiencies, weak political will and implementation as well as insufficient funding.
Then, in 2010, Pakistan’s national government devolved the two ministries by ratifying its 18th Constitutional Amendment, transferring nearly all ministry functions to health and population welfare departments in individual provinces.
And that’s when things really start getting complicated.
Surely, greater provincial autonomy may provide an opportunity to develop strategies better aligned with specific, local family planning needs. On the other hand, provincial governments may lack the capacity to adequately carry out new functions. Even worse, women’s health issues may be deprioritized in provinces and districts where patriarchy dictates political and budgetary decisions.
Several years later and here’s what we know:
- Pakistan committed to a series of reforms at the London Summit on Family Planning (now called FP2020) in 2012, including increasing domestic family planning expenditures over time, offering more birth spacing services and increasing contraceptive prevalence to 55 percent by 2020. While the pledges were a result of concerted CSO advocacy, it’s unclear whether these pledges have translated into action or results.
- It’s difficult to gauge the provinces’ approach and commitment to family planning from a policy perspective. There’s a vision for Pakistan’s future development, articulated by the Ministry of Planning, Development and Reforms. At the national level, the annual plan contains specific mention of improving the female community health worker program as well as the population welfare program. But development plans by province, beyond top-line budgets, are much more difficult to track down.
20 percent of women in Pakistan have an unmet need for family planning.
- Since the devolution of the two ministries and their functions, there’s no national population policy. Some provincial health departments have articulated sector strategies (see Punjab’s strategy and Sindh’s strategy). But, these pertain to the health departments only, which means their impact on family planning extends only to female community health worker programs. Moreover, it’s hard to tell whether provincial health and population welfare departments are working in a more coordinated manner.
- There’s a steep learning curve as far as health financing in a post-devolution Pakistan is concerned. Historically, the Public Sector Development Program—which funds family planning activities in Pakistan—has been challenged by the costs of natural disasters, security threats, and the persistent growth in new development projects. Hence, funding for family planning has fallen short of needs. In light of the additional revenue provided to the provincial governments post-devolution, it will be especially pertinent to monitor budgets and expenditures to ensure efficient use of resources for family planning.
- We need to remember that stakeholders beyond the public sector are actively engaged in family planning in Pakistan. In fact, much of Pakistan’s family planning services are provided by NGOs and the private sector, including Greenstar Social Marketing, the Marie Stopes Society and Rahnuma-Family Planning Association of Pakistan. Recently, Population Council’s Family Advancement for Life and Health (FALAH) program, a community-based project intended to promote the concept of birth spacing, saw an 8.5 percent increase in contraceptive use in project districts and may serve as an important programming model moving forward.
Although many questions about Pakistan’s current family planning efforts remain unanswered, one number serves as an important reminder of the mission ahead: 20 percent of women have an unmet need for family planning. It’s time to move beyond the confusion surrounding devolved policy and service delivery and toward focused, coordinated, well-funded and transparent family planning programming at national and sub-national levels.
The Demography Dish is a new monthly blog series featuring trends and analysis about demography and development. To read Part I of our Pakistan analysis, click here.