Population Policy 2002 & Programme 2003-10
(Review & Analysis)

I.       Evolution of Structure and Legal Frame Work

3.1.            Pakistan is one of the first few countries which made a pioneering effort in the field of family planning.  This initiative was taken by an NGO named ‘Family Planning Association of Pakistan’ in 1953. The Government of Pakistan, in the 1st Five Year Plan, 1955-60, endorsed the need for family planning and allocating Rs.5 million for disbursement to voluntary organizations for contraceptive advice and services.

3.2.            Because of the limited reach of the NGOs to cover population on a large scale, family planning services were provided through the outlets of the health departments during the 2nd Five Year Plan, 1960-65.  To oversee these activities, small independent units were established in the Ministry of Health and Provincial Health Departments.  In addition, medical and social research projects were initiated through donors as a support activity.

3.3.            In 1964, an evaluation revealed that the services were not reaching the target population through the health outlets as these were overburdened with the existing health care needs of the people.  Consequently, a full-fledged National Family Planning Programme was launched during the 3rd Five year Plan, 1965-70, and independent administrative structures in the shape of Federal councils, Provincial Councils and District Boards were established to run this activity. The prominent features of the programme were:  involvement of “dais” as motivators, providers of conventional contraceptives and referrals for clinical services (IUD); family planning education and communication through mass media, etc.      

3.4.            In the 4th Plan period, Continuous Motivation System was conceived under which “dais” were replaced by literate (Matriculate) teams of male and female motivators for each union council.  This was experimented during the extended 4th Plan period, 1970-78.  These teams of motivators undertook registration of all households and fertile couples to ensure continuity of family planning services. 

3.5.            In the first half of the 5th Year Plan, 1978-83, the family planning programme (now renamed as Population Welfare Programme) underwent several organizational and structural changes.  The programme was federalized in 1976 and Population Welfare Programme (Appointment and Termination of Services) Ordinance 1981 was issued to regularize the services of its employees through the Federal Public Service Commission.  During this plan period, the programme strategy was changed from the single purpose family planning approach to multi-sectoral and multi-dimensional approach that involves the relevant public sector organizations providing broad-based programme coverage. For effective coordination and implementation of this multi-sectoral approach, the Population Welfare Division was placed under the Ministry of Planning and Development.

3.6.            During the 6th Plan period, 1983-88, a major change in the Programme came in 1983 with the transfer of field activities of the Population Welfare Programme to the provinces, through the promulgation of “Transfer of Population Welfare Programme (Field Activities) Ordinance 1983. The multi-sectoral and multi-dimensional approaches, however, continued with renewed zeal for effective implementation during this period.  Another major initiative that was taken during this plan period was to institutionalize NGO Coordination Council, with representatives from NGOs of all the provinces, was established. Setting up of National Institute of Population Studies (NIPS) to undertake research, evaluation and surveys to help the national programme to have an empirical basis to formulate its strategies and approaches was the third major initiative taken during this period.

3.7.            The Population Welfare Programme received substantial political support during the 7th Plan period, 1988-93, when the status of the Population Welfare Division was raised to that of a Ministry and it received considerably enhanced allocation of funds.  The multi-sectoral and multi-dimensional approach of the past Plans was continued with emphasis on quality of services combined with intensified motivational campaigns.

3.8.            In the 8th Five Year Plan, 1993-98, a village-based family planning workers (VBFPW) cadre was created for better IPC and extended outreach and door step service delivery in the rural areas. For this purpose a VBFPW was posted in every village with population of 1500 or more.  To decentralize administrative management, monitoring and supervision, divisional directorates and tehsil offices were created during this Plan to resolve day-to-day problems and establish close coordination with other related departments and NGOs at the field level. However it was during this period when the employees of the programme working under the Population Departments, who had been made provincial employees through an Ordinance in 1983 when the field activities were transferred to the provinces, were declared to be continuing as federal civil servants by a judgment of the Supreme Court announced in 1993.

3.9.            The programme during the 9th Five Year Plan, 1998-2003, was developed on the positive elements of the strategies of the previous plans, ensuring continuity and consolidation of gains.  The programme focused on strengthening of outreach through enhanced and improved service delivery strategy with special attention to rural areas.  A broad-based reproductive health approach was adopted in the light of ICPD 1994 with emphasis on family planning, mother care and child health in the social context of the country.

3.10.        In the year 2000, a Review Committee was constituted for Assessment of Population Welfare Programme. Extensive consultations with different stakeholders including four Provincial Governments were undertaken and a report was submitted in April 2001. Based on the recommendations of the review committee, the following decisions were taken:

i.             The status of Population Welfare Programme shall be maintained as a separate Population Division and a stand-alone          Ministry.

ii.           There shall be separate Population Welfare Departments and    Health Departments at provincial level.

iii.         The VBFPWs of the Ministry of Population Welfare shall be    transferred to the Ministry of Health w.e.f. 1^st July, 2001.

iv.         The Population Welfare Departments shall be funded through Federal PSDP up to 2003. After 2003, the funding shall be provided through NFC award. In case the award is not finalized, the funding shall continue through Federal PSDP.

v.           The status of the Federal Civil Servants be changed to Provincial Civil Servants through amendments in the Ordinance title “Transfer of Population Welfare Programme (Field Activities) Ordinance, 1983”.

vi.         The administrative and financial control over the service delivery infrastructure (FWCs, RHS-As, MSUs) shall be transferred to the Provincial Population  Welfare Departments along with their staff, equipment and funds.

vii.       Family Health Workers shall provide contraceptives free of cost to the users.

viii.     The Family Health Workers shall be trained in midwifery by conducting short course.

3.11.        In pursuance of the decision at (v) above, an amendment to the Transfer of Population Welfare Programme (Field activities) Ordinance 1983 was issued on 25th July 2001 whereby the status of the federal civil servants in the Provincial Population Welfare Departments was changed to that of provincial civil servants. All the employees working in the PWDs became provincial civil servants.

3.12.        Ministry comprises of a division and under the Rules of Business, its business is attached as Annex-II. Further more, under the transfer of Population welfare program (Field Activity) Ordinance 1983, the functions of Federal & Provinces have also been defined.  Under this law all powers and functions of the Federal Government in respect of Field Activities vests in the Provincial Governments. Field activities have been defined in Section 3 ( c ) of the  Ordinance as under:

i.                    Provision of Population Welfare Motivational Services by establishing contacts with the clients at all levels;

ii.                  Provision of Family Health Service, Clinical and Non-clinical contraception through Family Welfare Centres and those Reproductive Health Service Establishments located in the Provincial Government hospitals, and, particularly, provision of services for rural areas;

iii.                Provision of Population Welfare motivation and services through line departments of the Provincial Governments;

iv.                Supply of contraceptives and medicines to the desirous clients in urban and rural areas of the districts through the network of community distribution points, and other agencies involved in the programme;

v.                  Implementation of publicity and communication strategy;

vi.                Promotion of community involvement and active participation in Population Welfare Programme activities;

vii.              Coordination of Population Welfare Programme activities with other nation-building departments at district and local levels;

viii.            Setting up of Advisory Management Committees at Family Welfare Centre level and Population Welfare Councils at district and provincial levels as provided in the Population Welfare Plan 1981-84; and

ix.                Any other activity of the Population Welfare Programme that the Federal Government may specify.

3.13.        Under the Law, the Federal Government continues to perform all functions pertaining to National Policy, planning and coordination, information, training, supplies, Statistics, monitoring and evaluation, research and foreign assistance.

3.14.        Population Welfare Programme is funded by the federal Government through PSDP and implemented by the Provincial Governments including AJK, FATA, G.B and ICT. One line budget of the Population Welfare Programme is transferred to the provinces by Ministry of Population Welfare through State Bank of Pakistan. Ministry of Population Welfare regulates the expenditure of Federal component including NIPS, NATPOW, AJK, FATA, G.B, and ICT.

II.      Population Policy 2002

3.15.        The “Program of Action” agreed at the International Conference on Population and Development held in Cairo in 1994 and Millennium Development Goals agreed during the UN Millennium Summit 2000 played important role in developing population policy and program dimensions. Keeping in view these international commitments, Pakistan evolved the following policy framework:

• Pakistan Population Policy 2002;
• Population Sector Perspective Plan 2002-2012
• De-federalization of the Population Welfare Program with fiscal and administrative authority (July 2002)
• Poverty Reduction Strategy (PRSP) paper 2003
• National Health Policy (2001) - recognizing family planning as integral and essential part of its activities
• National Policy for Development and Women Empowerment 2002
• National Education Policy 1998 targeted 'education for all' and reduction in disparities. Education for All Plan of Action in 2003
• Establishment of district governments under Local Government Ordinance 2001

3.16.        Being signatory to the Programme of Action of the International Conference on Population and Development (ICPD), Pakistan adopted the National Reproductive Health Service Package in 2001, thus promoting family planning within the broad framework of reproductive health. The Population Policy 2002 had therefore a shift in focus from merely reducing population growth rate through Family Planning to a greater emphasis on providing broad based reproductive health services. This certainly diluted the focus of the Program on population planning.

3.17.        Fertility decline was very fast when the Population Policy 2010 was being formulated. The Population Projections were drawn up by the Planning Commission in 2005, in line with the Population Policy, 2002.  There were expectations that this decline would continue with the same speed and the replacement level fertility would be easily achieved by 2020. But these hopes floundered when the contrary evidence came from the Pakistan Demographic and Health survey 2007.

3.18.        The Policy though had a marked success in the revival of interest in population issue and it was able to underscore the need to collaborate with other institutions in the public and private sector and NGOs but predominantly it could not achieve its targets. The decline in total fertility rate from 4.8 to 3.7 has been largely a result of rising age at marriage and high abortion rates rather than changes in contraceptive prevalence. The ever use of contraceptive is almost 50 percent but current use is 30 percent, which indicates a large proportion of dropouts and serious failure of take off in the family planning.

3.19.        Expansion in family planning services have not been able to keep up pace with the increased demand despite 25% unmet need. Stagnating contraceptive prevalence rates at 30 percent from 2001-2007; the high levels of unwanted fertility and the large number of induced abortions are reflection of this reality. More than one out of three women want birth spacing, however not using contraceptives. These outcomes are largely a result of not having easy, accessible and affordable resort to means of preventing an unwanted pregnancy, which includes good quality information and services.

3.20.        The Population Policy 2002 envisaged achieving universal access for FP/RH service by 2010 and the replacement level fertility (2.1) by 2020. Similarly, Population Perspective Plan (2002-12) targeted to achieve CPR at 57% by 2012. However, in the prevailing circumstances, with the existing CPR at 30% and TFR at 2.6 and with high unmet need of 25%, it would not be realistic to strive achieving these targets. In fact current trends in fertility if extrapolated, the replacement level appears hardly achievable by 2020 as envisioned in population policy 2002. The situation, therefore, calls for rationalizing goals and objectives of the Population Policy, 2002.

II.               Population Program 2003-08 & 2008-10

Out Come / Impact Review 

3.21.        As against the Contraceptive Prevalence Rate (CPR) target of 44.92% for the Year 2008, the CPR has even declined from 32% (2003) to 29.6% (PDHS 2007). Similarly, the Population Growth Rate (PGR) has stagnated at 2.05 percent against the target of 1.72 percent and the Total fertility Rate (TFR) has slightly declined to 3.6 against the target of 3.3 per woman. Reduction in Unmet need for Family Planning and RH Services has been brought down to 25% as against the target of 20 percent.

3.22.        Discontinuation of contraceptive use and lack of follow-up are the other major reasons for the stagnation of the CPR. In particular, the fear of side effects – especially of oral pills, injections and intra-uterine contraceptive devices (IUCDs) – of contraceptives has emerged as an important barrier to their use. Moreover, because of low quality of services, the programme could not attract new clients and ensure continuity of use. Irregular supply and non-availability of contraceptives at health facilities was another obstacle to the smooth provision of family planning services.

3.23.        The trend of contraceptive mix shows female sterilization and use of traditional methods as the major means of practice, but they have had a limited impact on the TFR. Over the years, four important issues have emerged: 1) decline in the use of three major methods of contraception (oral pills, injectables and IUCDs); 2) persistent unmet need for contraception; 3) widening gap between current and ever use of contraception indicating dropouts; and 4) high incidence of abortion (including induced).

3.24.        The PDHS 2006-07 reveals that about 10 percent women experienced a miscarriage or an abortion during five years prior to the survey. A study undertaken by the Population Council in 2004 estimates around one million (890,000) induced abortions occurring annually in Pakistan. This phenomenon, when examined in relation to high unmet need, demonstrates the health risks Pakistani women face during their reproductive life.

3.25.        The Programme has for the last many years focused on promoting small family norms through awareness and motivational campaigns. This strategy has been partially successful in raising the level of awareness about population issues, but it has not been able to bring about the desired change in attitudes and behavior. There are several reasons for this: first, the campaign has focused primarily on urban areas, while rural and semi-urban areas could not be targeted effectively; second, the majority of the rural population could not internalize the message due to low literacy rate; third, access to information and the quality of counseling remained poor, because the fear of side effects of contraceptives could not be taken out of the people’s minds; fourth, the service providers, though given training on inter-personal communication (IPC) and information, education and communication (IEC) skills, lacked a professional flair to motivate and counsel eligible couples to adopt contraception; and fifth, religious and socio-cultural apprehensions about family planning could not be fully addressed.

3.26.        The support from the health network, both at the federal and provincial levels, for the provision of FP/RH services remained modest since this area did not get the attention it deserved. The performance of lady health workers in providing FP/RH services was also found lacking (Third Party Evaluation: Oxford Policy Management, 2009). More importantly, the coordination between the MoPW and the MoH as critical partners and stakeholders was weak at all levels. As a result, the goal of achieving universal access to family planning services by 2010 could not be achieved.

3.27.        The service delivery network of the Programme has expanded modestly over the years, but little attention has been paid to outreach services. Moreover, the combination of the network has not been worked out scientifically to address the issue of programme coverage and access in relation to settlement patterns, population density and geographical terrain. The neglect of service delivery points for men has also been noted. The weakness in the monitoring system, superimposed by the target-oriented approach, prompted inflated reporting. Furthermore, evaluation studies of service components undertaken by NIPS reveal a number of operational problems impeding optimal performance.

3.28.        The envisioned public-private partnership (PPP) initiative had tremendous potential, but it could not be fully tapped and the target population remained underserved. The same is true for social marketing companies (SMCs) though they have been an active partner of the MoPW in meeting the family planning needs of the people living especially in urban and semi-urban areas.

3.29.        The Programme could have made an efficient use of the vast physical infrastructure of non-governmental organization (NGO), including national and provincial Rural Support Programmes (RSPs). Considering this, it is unfortunate that apprehensions about facilities providing family planning services continue to exist and the number of clients visiting the service centers remains low. On the other hand, research indicates that more and more women want to space their next pregnancy, implying that the latent demand for family planning services is high but fragile, particularly among rural communities, because of limited female mobility.

3.30.        The service delivery of the Programme focused more on promoting sterilization and less on pregnancy spacing. The PDHS 2006-07 shows that a significant proportion of Pakistani women continue to conceive and give birth in serious health and life risk conditions, such as childbearing in teen ages; childbearing after age 34; short birth interval; and four or more births.

3.31.        Demographic surveys consistently reveal a significant reduction in neonatal and infant mortality as a result of pregnancy spacing of two to four years; if translated into appropriate strategies, this could bring about the desired fertility transition. The thrust of future service delivery strategy should, therefore, be on healthy timing and spacing of pregnancies.

3.32.        Similarly, international comparative studies reveal benefits of family planning for maternal health and child survival. These studies clearly bring out that there would have been around four million additional maternal deaths during 1985-2005 had there been no increase in family planning use over the level of 1985. Similarly, 54 percent additional maternal deaths are projected to occur during 2005-2025 if no increase in family planning use is recorded over the level of 2005. Furthermore, research shows that increased use of contraception is associated with reduced rate of abortion. This demands that the Ministry and Provincial Departments of Health provide family planning services at all their outlets.

Governance Issues

3.33.        The poverty reduction strategy paper (PRSP) worked as a pretext for enhanced financial support to the Program over the following several year, however, the prerogative position assigned to MDGs over ICPD Plan of Action put the issue of addressing high fertility on the backburner and family planning went off government's priority radar. The tacit support to 1970s call: 'Development is the Best Contraceptive' by senior politicians and planners, overemphasized achievement of economic growth at the cost of population sector priorities.

3.34.        The situation became even more exacerbated with international donor funds shifting away from family planning and towards reproductive health in general and HIV/AIDS in particular. As a consequence, the Program could not keep pace in extending the services compatible with the emerging requirements. High level of unmet need for family planning (25%) and stagnation of demographic indicators provide sufficient evidence to substantiate this situation.

3.35.        There is a tacit acceptance at the highest level that Pakistan has strayed from prioritizing population planning program and committed notional funds for family planning and reproductive health. As against the overall approved cost of the plan (2003-08), amounting to Rs. 21.02 billion, the PSDP allocations were reduced to Rs.18.87 billion against which only Rs. 17.06 billion were released during 2003-08 while utilization was allowed up to Rs. 14.54 million by the Finance Division. Similarly, against allocations of Rs. 4.709 billion and Rs. 14.162 billion for the Federal and Provincial Population Programs (2003-08), the Government was able to provide Rs. 3.207 billion and Rs. 11.349 billion respectively.

3.36.        The Programme was de-federalized in 2002 with the financial, administrative and operational authority transferred to the Provincial Population Welfare Departments (PWDs). To give time and space to the provincial governments to take over the Programme, the federal government agreed to continue its funding through the Public Sector Development Programme (PSDP) for the first three years or until the finalization of the next National Finance Commission (NFC) Award. Because of the delay in the finalization of the NFC Award and resource constraints of the provincial governments, the federal government continued to fund the Programme. Consequently, the provincial governments did not develop the desired level of ownership.

3.37.        The funding of provincial Population Programs was to be incorporated in National Finance Commission Award to enable provincial ownership of the Program. Revision of NFC award sidelined the transfer of Population Welfare funds to provincial governments.

3.38.        The whole administrative structure of Pakistan was devolved at district level under the Local Government Ordinance 2001 with the creation of District Offices; the de-Federalized Population Welfare Program remained un-devolved in the district government.

3.39.        Although family planning service delivery points have increased and the prices of contraceptives have remained unchanged over the last few years, access to services still remains a problem area. The Programme’s community-based service delivery model involving village-based family planning workers (VBFPWs) showed good results in 1990s, but the trend could not be sustained since this cadre was merged into that of lady health workers (LHWs) of the Ministry of Health (MoH) in 2002. Consequently, the Programme lost its focus on community-based access to contraceptive services and the attention shifted to static facility-based services.

3.40.        Ban on recruitment and vast vacant positions, especially of service providers in the service centers coupled with the absence of grassroots workers created a huge vacuum in service provision especially to rural masses. The position further worsened when the Ministry and Departments of Health, having endorsed revised National Health Policy 2002, did not give due priority to the provision of family planning services and as such the support needed to bridge the gap especially in rural and remote areas could not come forth. Limited role of non-governmental bodies to bridge the service delivery gap further aggravated the situation.

3.41.        Other governance issues especially Program oversight requiring efficient feedback from the field including beneficiaries, with due periodic assessment, remained weak across all sectors responsible for family planning provision.  Resultantly, the goals set during the ICPD or those that came as a result of UN Millennium Summit are no more achievable. It is argued that Pakistan has been unable to keep the balance between the two agendas and lost the track in finding ends of either of the two (Abrejoet al.; 2008). The political realization of the growing population has remained confined to policy statements rather rhetoric. The fertility stagnation is not surprising given these serious management problems and absence of political will to address this priority issue.

3.42.        The Population Policy 2002 has set for itself achievement of replacement level by 2020. The Perspective Plan 2002-12 identified TFR level of 2.8 for 2012 with a CPR of 53 percent. The most recent PRSP-II document (dated Nov 2008) rather sets TFR of 3.25 for 2010-11 with a CPR level of 37.5 percent, which does not appear to be internally consistent with the Perspective Plan. Ultimately, Pakistan will have to evolve strategies that are consistent with international findings that show a CPR level of around 70 percent to achieve TFR of 2.1 (Ahmed et al. 2006). Pakistan has committed to achieve the CPR target of 55 percent by 2015 to show its willingness to support sectoral development process. Keeping in view, inconsistency between 'what is required' and 'what is committed', the delay in achieving the policy goal (replacement level fertility) appears obvious.

3.43.        A thorough exercise to revisit the Population Program policies, strategies, interventions, partnerships, and financial requirements is urgently needed to bring family planning to centre stage of all development activities. The focal point of all family planning activities should evolve from provincial commitment with dedicated support to enhance access, coverage to services and through functional integration. Financial flow mechanism needs to be straightened to meet the coverage, access and quality of service standards on highly 'enthusiastic and ambitious' course of action to gain lost momentum. Outreach interventions including rejuvenation of male mobilizers and other innovative interventions to upscale useful practices needs urgent addressing of the problem leading to unmet need, and build strong partnership to achieve the same. Program would still need to be closely linked with the support of stringent social measures including compulsory education with increased pace in female education (till 10th grade), increasing opportunities of female work, and curbing child labor using legislation and regulation, which may hasten the achievement of replacement level fertility.

3.44.        A robust FP/RH programme is, therefore, imperative to regain the momentum in fertility transition. It needs to give focused attention to the unmet need (25 percent) for contraception by addressing issues of misinformation and misperception, limited access to services, lack of client-focused care and quality services, and lack of choice of contraceptive methods. An aggressive communication campaign is required to enhance social acceptance for the programme. At the same time, vigilant and effective monitoring and regular evaluation is needed. This makes it all the more necessary that family planning be mainstreamed in the health policy, as well as into all other development initiatives.

III.    Policy Recommendations

3.45.        Pakistan's population which is increasing annually by a little less than four million people will make it the fifth most populous country in the world by 2015. This massive change in population calls for serious realignment of its population policy with the emerging realities. The prime focus, therefore, is an urgent need to achieve all development related goals and targets by mustering support for family planning program and by bringing population goals at the centre stage of the development process. Political will to carry forward population agenda which has varied in the past with respect to Program priorities and support by other sectors, must show acumen towards long term national gains. Revitalization of the family planning agenda is imperative and an urgent need of Pakistan. Greater focus and investment in family planning in Pakistan is central to achieving the lost momentum of fertility transition, and of course the Millennium Development Goals.  Some substantive recommendations that emerge from this analysis include:

3.46.        The decade of 2010-2020 must be declared as the 'Decade of Fertility Transition' to attract comprehensive investments to launch massive family planning initiatives to address all priority social sector goals and targets set for population, health and education sectors.

3.47.        Management of Population Welfare Program should proceed as envisioned under the de-federalization plan that entails provincial ownership and provision of support through NFC Award. Utmost attention should be given to human resource development for smooth operational implementation.

3.48.        Three areas are critical to attaining early fertility transition goals: coverage, access, and quality of family planning services. All stakeholders need to develop strategic partnership to ensure that family planning is taken up as the core activity and complemented by knowledge creation and provision of accurate information. Ensuring all three areas fully implemented, the onus lies on the public sector.

3.49.        Family planning campaigns need to reposition as a vital well-being health intervention focusing primarily on pregnancy spacing and method-specific promotion. The image of limiting family size and number of births need to be replaced by healthy spacing of births and health benefits to mother and child. Contraceptive method mix in Pakistan, therefore, needs to shift now to focus on spacing methods, to be consistent with healthy spacing focus of services and communication efforts.

3.50.        Initiatives launched under the Public Sector umbrella should primarily target rural women especially those who are young, married and are in their reproductive ages. Expanded role of private sector along with NGOs to reach out to women in remote areas is essential for success. Functional integration must be established at all levels between Population Welfare and Health facilities to complement and enhance coverage.

3.51.        Involving religious leaders has been a well tested innovative initiative in a number of Muslim countries, and have shown positive results in this regard by effecting spacing of pregnancies and births, demand for children and use of contraception. This needs to be organized in Pakistan to remove misconceptions of contraceptive = use associated with religion and to enhance contraceptive use.

3.52.        Women empowerment and female education need long-term financial and professional commitments. These are critical drivers to bring about important behavioral change to overcome barriers to family planning. Research has time and again shown fatalism to be one of the barriers to family planning promotion in Pakistan. Fatalism is deeply rooted in Pakistan's social fabric and can only be challenged provided economic cost of bearing and raising a child to a family, and loss due to women's inability to contribute economically is fully realized. Broader education and communication programs using interpersonal communication interventions are needed to overcome social and cultural barriers to family planning, including misconceptions and myths about contraception.

3.53.        Enhancing female education is a long term effective strategy required for fertility transition. Current targets of achieving 100 percent female enrolment in 10th grade by 2025 is not consistent with Pakistan's target of achieving replacement level fertility. These need to be revised downwards to achieve universalisation of female enrollment by year 2020 to enable achievement of replacement level fertility by 2027. There should be no compromise on female education targets.

3.54.        Persistently high demand for children is a serious impediment to fertility transition and must be addressed using multi-sectoral strategy. Recent surge in inflation and increased proportion of population living under poverty has again brought back the positive link between 'demand for children' to supplement family income and 'household poverty'. It is essential that Pakistan learns from regional best-practices, such as of Iran and Bangladesh, for reducing high demand for children.

3.55.        Pakistan's current economic recession and crises appear to have negative bearing on female opportunity costs and to their overall empowerment process. Access to credit on long-term basis is needed to provide necessary impetus for reducing the demand for children and increasing the use of contraception.

3.56.        Demand for child education needs to show significant increase over the coming years. Child labor continues to be one of the major impeding factors for the population welfare goals exerting upward pressure on the demand for children, especially among the rural strata. Stringent regulation of compulsory child education laws must be adopted by provincial authorities to promote enrolment and retention, especially for females.

3.57.        Lastly, National Population Commission was established in 2002 (as a public sector body) which met only once soon after establishment with the Prime Minister in the Chair. This Commission could not contribute substantively towards population sector goals and programme performance. An independent population professional think tank - 'Population Monitoring Commission' - is proposed purely to focus on ensuring that family planning and population issues become centre stage of all development plans for the next decade or so. Commission will have nothing to do with implementation of the programme. The main facilitative functions of the Commission are envisioned to encompass: providing a forum for consultation on policy and programmatic initiatives, rapid assessments, regular third-party evaluations, reviewing inter-sectoral linkages and support plans to achieve fertility targets, critical assessment of initiatives, and facilitation for initiatives for removal of barriers and meeting unmet needs. Monitoring provincial ownership will be a critical function that the Commission can perform on priority.

Chapter - 4

Way Forward

     I.            Revitalizing the Imperative

a).        Population and Development

4.1.            Rapid urbanization, technological advancement, increasing female literacy and better job prospects for women, proliferation of information through the media, and competitive market forces have set in the process of transformation in social values and lifestyles. As a result, the recent demographic surveys show that the TFR has declined in urban areas, while it is comparatively higher in rural areas, though finally declining.

4.2.            The high PGR and TFR pose serious challenges to Pakistan’s development as pressure on urban agglomerates is increasing, and an additional burden is being put on the already limited educational and employment opportunities for the youth. The changing age structure, resulting in an increasing number of youth entering the labour force, is further compounding the situation. The increase in population density, mushrooming urban slums, rapid depletion of water resources, deforestation and loss of arable land due to urban development are some of the manifestations of rapid population growth.

4.3.            Reduction in poverty has been an essential part of all economic policies, particularly in the light of the Millennium Development Goals (MDGs), yet over one-third of country’s population continues to live below the poverty line (BPL) with the absolute number of poor increasing. Regional variations in poverty are pronounced and well-recorded for Pakistan. The increase in poverty has a close relation to high fertility, especially among the lower strata of society.

b).       Reproductive Health and Family Planning

4.4.            The Population Policy of Pakistan 2002 aimed at accelerating fertility transition to attain replacement level fertility by 2020 and the Population Perspective Plan (2002-12) envisaged CPR of 57 percent by 2012. It goes without saying that these were overambitious targets. The situation, therefore, calls for rationalizing goals and objectives of the Programme, as well as rearticulating roles and responsibilities of all the stakeholders.

4.5.            Pakistan currently recognizes, more than ever before, the need to lower the PGR and TFR to be consistent with its development and welfare priorities. It also realizes that this requires strong political support; improvement in literacy rate, particularly of women; and reduction in poverty.

4.6.            A new population policy with revised goals and rational targets is imperative to accelerate the fertility transition to reap the demographic dividend, besides focusing on the implementation of the Programme of Action of the ICPD and the achievement of the MDGs. The policy should provide clear guiding principles, a comprehensive strategy and a plan of action for all the stakeholders to realize a shared vision for the next at least 20 years.

II.            Proposed Pakistan Population Policy 2010

4.7.            The proposed Population Policy should place the ‘population factor’ at the centre stage of national development planning. It should recognize reproductive health as a critical component of sustainable socioeconomic development having string linkages with the government’s poverty reduction strategies. The Policy should reposition family planning as a health initiative, with a focus on maternal health and child survival, by making family planning services a vital component of the essential services package. Within this holistic perspective, and in the wake of emerging demographic realities, the proposed Policy should re-emphasize timely completion of fertility transition for stabilizing the population and reaping the demographic dividend.

4.8.            Infused with this spirit, it is expected that the Policy would contribute meaningfully to the implementation of the Programme of Action of the ICPD and the achievement of the MDGs, particularly reducing the maternal mortality ratio by two-thirds by 2015.

i).             Vision

4.9.            The Policy 2010 would promote a prosperous, healthy and skilled society where every pregnancy is planned; every child is nurtured and cared for; and every citizen is provided with choices to improve the quality of his or her life.

ii).           Goals

4.10.        The Policy 2010 seeks to:

§  Accelerate the completion of fertility transition for achieving population stabilization;

§  Enhance human development for capitalizing on the unique opportunities offered by the emerging demographic scenario (demographic dividend); and

§  Increase pregnancy spacing for improving the health of women and children.

iii).        Objectives

4.11.        The short-term objectives of the Policy 2010 are to:

§  Make available family planning services to the remotest areas of the country by 2015;

§  Reduce the unmet need for family planning from the current 25 percent to 20 percent by 2015;

§  Reduce the TFR from the current 3.6 births (Projections by the Planning Commission’s Working Group on Population Sector, 2010) to 3.2 births per woman by 2015;

§  Ensure contraceptive commodity security for all public and private sector outlets by 2015; and

§  Improve maternal health by encouraging pregnancy spacing of more than 36 months, reducing the incidence of first birth among those mothers aged below 18 and discouraging the trend of mothers giving birth after age 34 and above, thus contributing to the achievement of the MDGs 4 and 5.

4.12.        The long-term objectives of the Policy 2010 are to:

§  Attain replacement level fertility by 2030;

§  Achieve universal access to family planning services by 2030;

§  Reduce the unmet need for family planning from the current 25 percent to 5 percent by 2030; and

§  Increase the CPR from the current 30 percent to 60 percent by 2030.

iv).        Principles

4.13.        The principles of the Policy 2010 are based on the Programme of Action of the ICPD, the MDGs and the Karachi Declaration 2009. These are to:

§  Promote reproductive health as an entitlement, based on voluntary and informed choice;

§  Address the population issue within national laws and development priorities, while considering the social and cultural norms;

§  Ensure active, responsible and accountable participation by all the stakeholders; and

§  Promote programmatic interventions on the basis of scientific evidence.

v).           Assumptions

4.14.        The Policy 2010 is based on the following assumptions:

§  Sustained political commitment at the federal and provincial levels;

§  Full ownership of the Programme by the provincial governments by 2015 and programmatic interventions by them to reduce the unmet need;

§  Enhanced resource availability for the Programme under the NFC Award;

§  Mandatory provision of family planning services by the Provincial Departments of Health and adoption of family planning as an essential health intervention by the MoH;

§  Centre staging of the population factor in national development planning for reaping the demographic dividend; and

§  Broad-based multi-sectoral support.

vi).        Strategies

4.15.        The Policy 2010 lays emphasis on reaping the unprecedented demographic dividend, as envisaged by the Planning Commission’s Vision 2030 document. This necessitates adopting human development policies that can help transform the young population into a skilled workforce It situates reproductive health and family planning within the context of overall economic and social development, thus creating linkages with other developmental concerns, such as increasing the provision and outreach of primary and secondary education, empowering women and creating employment opportunities for the people.

4.16.        The Policy 2010 also stresses upon putting in place an effective reproductive health programme that ensures the continuation and speeding up of the fertility transition process. It therefore, attaches special importance to achieving universal access to FP/RH information and services. The policy 2010 recognizes that achieving fertility transition is a collective national responsibility of all potential providers in the public, private and NGO sector and provides for involving all the stakeholders in achieving the stated goals and objectives through the adoption of the following strategies:

a)      Mainstreaming Population in Development Planning

4.17.        The population policy impacts all spheres of economic and social life. It is evident from the inter-linkages between population and development that demographic trends are, on the one hand, determinants of socioeconomic development and, on the other, are determined by it. Broad-based sectoral and inter-sectoral support is, thus, critical to realizing the goals of the Policy 2010. This includes building strong linkages between population and other social sector areas.

4.18.        Female education, in particular, is vital for achieving fertility transition. This is evident from the fact that the lack of emphasis on female education in Pakistan in the past has adversely affected the pace of fertility transition. Similarly, limited female employment has not allowed the country to accrue the benefits of women’s positive association with fertility transition. Adequate investment in young people so that they could develop marketable skills has also remained an unattended area in Pakistan, limiting their productive involvement in the society.

4.19.        In addition, rapid urbanization is putting an unprecedented pressure on the policymakers to cater to the growing need for services and amenities. The projected urbanization growth over the next two decades encompasses massive internal migration patterns and necessitates innovative population redistribution policies, such as building new towns and industrial zones. To address these issues, the institutions of the Programme would be strengthened, and all the stakeholders would be brought on one platform for reviewing the Programme and monitoring the progress made on goals and objectives. This would help evolve an integrated service delivery strategy to achieve synergy and facilitate reaping of the demographic dividend.

b)     Advocacy and Demand Generation

4.20.        The Programme has achieved a universal level of awareness, but there still exists a wide gap in the knowledge (of at least one method) and practice of family planning. The communication approach has to take this into consideration, and develop evidence-based, audience-specific and vibrant campaign to bring about necessary changes in attitudes and behaviour. The promotion of pregnancy spacing perspective of reproductive health needs special communication initiatives that emphasize its positive impact on maternal and child health. Pregnancy spacing is also in line with religious precepts and, thus, it provides a strong framework to solicit support of the religious community. The media – with its fast growing role in disseminating information, building public opinion and shaping societal behaviour – would be used to play a vital role in projecting and promoting voluntary adoption of small family norms and responsible parenthood. A strategy would also be devised to bring about positive changes in attitudes and behaviour towards the use of male contraceptives.

c)      Enhancing Access to and Improving Quality of FP/RH Services

4.21.        The Programme’s service delivery network of 3,416 centres (2,853 Family Welfare Centres, 271 Reproductive Health Service Centres and 292 Mobile Service Units) hardly covers 35.0 million people or slightly over 20 percent of the country’s population of 169.9 million. The goal of achieving universal access to FP/RH services by 2030 and reaching out to the remotest areas of the country by 2015 cannot be realized through the efforts of the MoPW alone; it calls for collective resolve by all the stakeholders.

4.22.        The Policy 2010, therefore emphasizes, filling the critical gap in access to FP/RH services through upgrading, expanding and integrating service outlets managed by the different stakeholders: the Ministry and Provincial Departments of Population Welfare, the Ministry and Provincial Departments of Health, the Planning and Development Division, the Ministry of Finance, provincial line departments, SMCs, private sector health professionals, population experts and civil society organizations (CSOs).

d)     Contraceptive Commodity Security

4.23.      Ensuring commodity security to cater to national needs for at least five years and uninterrupted availability of a complete range of contraceptives at affordable prices at all facilities is the lifeline of family planning services. In view of the projected increase in contraceptive uptake, additional contraceptive requirements are anticipated in coming years. Both commodity security and supply chain management system would be improved to avoid overstocking and stock outs at any level and any time.

e)      Training and Human Resource Development

4.24.        One of the major responsibilities of the MoPW under the Policy 2010 would be to implement the Programme professionally, so as to keep pace with other stakeholders and maintain national service standards while providing FP/RH services. This would require professional human resource to carry out a wide range of specialized functions. The Policy 2010, therefore, focuses on human resource development (HRD) in line with the emerging role of the Ministry and Provincial Departments of Population Welfare vis-à-vis other stakeholders.

4.25.        Managerial inefficiency and low quality of care and services are often cited as the major reasons for ineffective implementation of the Programme. However, they are not the causes; rather, they are an outcome of the cause: lack of capacity. For capacity building, the Programme has Population Welfare Training Institutes and Regional Training Institutes, but the outcome leaves a lot to be desired by improving professional faculty, curricula and its relevance to counselling and care, teaching and training methodology, and learning environment. Measures ranging from revamping these institutes to revisiting their supervisory structure and control mechanisms are therefore a prerequisite for bringing about a positive change in this situation.

f)       Research and Evaluation

4.26.        Drawing on research on different aspects of reproductive health, family planning and fertility transition, the Policy 2010 recommends an evidence-based approach for the Programme. It also encourages institutionalization of research on reproductive health and family planning to enhance the knowledge base for improved policies and programmes. Future research would focus on how fertility transition could be accelerated in the shortest possible timeframe. Research on improving access to services and addressing socio-cultural barriers would also be carried out to improve implementation of the Programme. Similarly, clinical and biomedical research would also be conducted to introduce new family planning methods. Furthermore, research on social mobilization, male involvement and innovative communications would be promoted.

g)      Public-Private Partnership

4.27.        Extending support to public-private partnerships (PPPs) is critical to expanding FP/RH services, both horizontally and vertically. The Policy 2010 envisages replacing the existing focus of the Programme on the private sector with an innovative approach, so that collaboration could be enhanced in those areas where FP/RH services are required. The approach would focus on extending outreach to rural areas and deepening efforts in urban slums. It would bring into its fold public sector organizations, corporate bodies, industrial concerns, private medical practitioners and CSOs/NGOs. Furthermore, the community-based service delivery model – partnering with the community for setting up village-based service facilities – would be adopted. Efforts would also be made to enlarge the social marketing network so as to encourage healthy competition. The vast social network of RSPs and other CSOs/NGOs would also be involved in social mobilization.

h)     Monitoring

4.28.        The Policy 2010 emphasises adopting a joint monitoring framework to ensure effective implementation by all the stakeholders. It envisages adopting the results-based monitoring (RBM) mechanism to ensure that processes and outputs contribute to the achievement of clearly stated objectives. This approach would shift the focus of monitoring from outputs (number of contraceptives distributed, number of clients contacted and recruited, etc.) to outcomes (increase in the CPR, etc.). Putting emphasis on outcomes is also important for the MoPW to engage stakeholders and build partnerships to achieve shared objectives.

4.29.        The monitoring framework would specify the indicators of input, service delivery process and output, which would be observed, reviewed and followed up regularly at the tehsil, district and division levels. Monitoring by the Provincial Population Welfare Departments would largely be a review of the district and tehsil level monitoring efforts. As a step towards activating the verification tool, the Provincial Population Welfare Departments would send their monitoring reports to the MoPW. These reports would be analyzed in regular review sessions on Programme implementation at the national level. The monitoring process, in order to be result-oriented, would also institutionalize the capacity to track and concurrently follow up the progress made in important aspects of the Programme. Since the operational monitoring would rest with the Provincial Population Welfare Departments, the MoPW would maintain supportive linkages with them, as well as enhance their professional capacity and skills.

vii).      Implementation Plan

4.30.        In the wake of recent constitutional amendment (18th amendment), though, the population welfare program would be transferred to the provincial governments, policy making and its execution, in view to ensure continuity and consistency of national development priority, would continue at the federal level through an apex body. This is also necessary to have an interface with United Nation’s agencies; for forging bilateral and multi-lateral agreements and coordination with International Development Partners. This would necessitate restructuring of the ministry and redefining its role vis-à-vis the Provincial Departments of Population Welfare, the Ministry of Health, the Planning and Development Division, the Finance Division, other social sector ministries, CSOs/NGOs and the private sector.

4.31.        In 2001, the Population Welfare Programme was defederalized through an ordinance ‘Population Welfare Programme (2001). The Administrative and financial control over the service delivery infrastructure (FWCs, RHS – As, MSUs) was transferred to the Provincial Population Welfare Departments along with the staff, equipments and funds.

4.32.         Considering the crosscutting nature of the population issue, participation of all the stakeholders in implementation of the Policy 2010 would be encouraged and supported. In addition, necessary mechanisms and institutional arrangements would be put in place to seek the support of elected representatives and local leaders, opinion makers, religious scholars and organized communities for efficient and effective implementation of the Policy 2010. Furthermore, academic and research institutions would be involved in monitoring the progress made by the Policy 2010.

4.33.        The implementation of the Policy 2010 would rest with the provincial governments who would do this in collaboration with the line departments, public and private sector organizations and NGOs/Civil Society Organizations in a way that conforms to social values and national and provincial development priorities. With the announcement of the 7th NFC Award, the provincial governments would have access to additional resources starting July 2010; therefore, it is expected that they would assume full ownership of the Programme.

viii).   Legal Framework

4.34.        In 1981, Population Welfare Planning Programme (Appointment and termination of services) ordinance-1981 was issued regularizing the services of the personnel through Federal Public Service Commission and Departmental Selection Committee. In 1983, the Programme was De-Federalized (1983) through an ordinance namely Transfer of Population Welfare Programme (Field activities) ordinance to provide for the transfer of field activities of the Population Welfare Programme to Provincial Governments. The institutional arrangement of the program attained the status of an independent Ministry on 12th June, 1990.

4.35.        In 2001, after an extensive review, the Population Welfare Programme was defederalized through an ordinance ‘Population Welfare Programme (2001), the funding, however, was to continue through Federal PSDP up to 2003; thereafter the funding was to be provided through N.F.C. award. The Administrative and financial control over the service delivery infrastructure (FWCs, RHS – As, MSUs) was transferred to the Provincial Population Welfare Departments along with the staff, equipments and funds.

4.36.        The institutions of ministry of population welfare like National Institute of Population Studies, National Trust for Population Welfare and National Commission for Population Welfare have been established through executive resolutions and need to be provided a legal framework. Partnerships with the private sector are without any formal legal cover which creates uncertainty among the Programme personnel and partners. Therefore, there is a need to develop a legal framework to strengthen and support the public –private partnership.

ix).        International Cooperation

4.37.        Pakistan is a signatory to the Programme of Action of the ICPD, as well as committed to achieving the United Nations MDGs. The Policy 2010, therefore, encompasses not only national development priorities but also international obligations. The MoPW envisages expanding the scope of its activities in accordance with the recommendations of the ICPD. Precisely against this backdrop, the Policy 2010 focuses on developing bi-lateral relations, especially with other Muslim and South Asian countries, and forging linkages with international development agencies, particularly for sharing best practices and seeking technical support.

4.38.        The Policy 2010 seeks enhanced financial and technical cooperation from the international community, anticipating that it would understand and appreciate the population and reproductive health situation of Pakistan and its implications within and beyond boundaries. It also urges the international community to fulfil its obligations under the ICPD and the development partners to realize their commitments with Pakistan.

Annex I: Programme of Action

The Policy 2010 would be implemented through Five-Year Population Welfare Plans, which would be part of the Five-Year National Development Plans. Every subsequent plan would be based on the evaluation of the previous one, as well as on the regional and global best practices. The 1^st Five-Year Plan of the Programme under the Policy 2010 would be an integral component of the People’s Development Plan 2010-15. The salient features of the Plan of Action to implement the Policy 2010 include the following:

a).  Mainstreaming Population in Development Planning

§  Strengthening the National Commission for Population Welfare (NCPW) through an appropriate legal framework for creating synergies with other social sector ministries and departments;

§  Bringing the population issue to the centre stage of development by emphasizing the implications and consequences of rapid population growth on different sectors of the society;

§  Aligning different social sector policies (particularly those relating to education, health, social welfare, women’s empowerment, labour, youth, employment, the environment and urban growth) and creating functional linkages between them;

§  Sensitizing the decision-makers to mainstream the population factor in national development planning; and

§  Formulating a joint action plan to synergize the human development initiatives of different government ministries and social sector organizations.

b).  Advocacy and Demand Generation

With a view to bridging the wide gap between knowledge (universal level of awareness: 97%) and practice, an aggressive communication campaign, which can bring about the desired change in behaviours and practice, would be adopted. This would entail:

• Bringing pregnancy spacing to the centre stage of programmatic efforts through appealing messages;
• Using multiple media channels with different thematic messages developed along scientific lines;
• Improving quality of counselling to emphasize benefits of family planning, and removing doubts and fears about side effects of contraceptives;
• Emphasizing mandatory counselling on pregnancy spacing during the antenatal and postpartum checkups and post-miscarriage;
• Utilizing the existing infrastructure of the public sector, as well as of CSOs/NGOs, for social mobilization to reach out to rural communities; and
• Using a multi-pronged approach to:

o   Involve public representatives, opinion leaders, journalists, lawyers, academicians, etc., to solicit their support in promoting pregnancy spacing, safe motherhood and responsible parenthood

o   Engage Imams and Khateebs at the village level to dispel socio-religious misconceptions about family planning

o   Keep the media updated on the latest happenings in the Muslim world and in the region to promote the objectives of the Programme

o   Promote male involvement in reproductive health and family planning through innovative community level initiatives, particularly in rural areas.

c).  Enhancing Access to and Improving Quality of FP/RH Services

§  Increasing the number of service delivery outlets:

• Family Welfare Centres (FWCs): from 2,853 to 5,255
• Reproductive Health Service (RHS-A) Centres: from 271 to 321
• Mobile Service Units (MSUs): from 292 to 346;

• Improving functional integration with service delivery points (13,000) of the MoH and the Provincial Departments of Health to:

o   Make available pregnancy spacing services at all the health centres where tetanus vaccination, antenatal and postnatal care, and child immunization are administered

o   Include contraceptives in the health essential drug list

o   Provide contraceptive services as part of primary health care

o   Include care for miscarriages /post-abortion in policies, guidelines, protocols and standards;

• Broadening networking with NGOs (500) for providing FP/RH information and services in the rural and remote areas through Family Health Homes (FHHs);
• Shifting the thrust of expansion of service delivery outlets from urban to semi-urban and rural areas, focusing on outreach and community-based service delivery under an institutional arrangement. While urban slums would receive priority, the bulk of services would be located in rural and remote areas;
• Developing partnerships with the national and provincial RSPs for social mobilization and expansion of service delivery;
• Expanding contraceptive choice and ensuring availability of quality family planning services and commodities, including emergency contraception, at all public and private sector facilities;
• Promoting pregnancy spacing methods at all facilities in line with the requirements of the clients;
• Focusing on the quality of service and client-centred training of the Programme personnel; and
• Carrying out analysis of Ministry and Provincial Departments of Health interventions for family planning and primary health care to develop functional integration between service providers.

d).  Contraceptive Commodity Security

An estimated amount (at constant price) of Rs. 6.5 billion for national contraceptive commodity security would be required to raise the CPR from the current level of 30.0 percent to 38.0 percent by 2015; Rs. 9.6 billion to raise it from 38.0 percent to 45.5 percent by 2020; Rs. 12.8 billion to raise it from 45.5 percent to 54.0 percent by 2025; and Rs. 14.0 billion to raise it from 54.0 percent to 60.0 percent by 2030. Ensuring contraceptive commodity security, being a basic requirement for dispensation of family planning services, calls for developing an independent institutional arrangement (limited company) to carry out the following:

• Institutionalizing population projections while taking into account changing trends in contraceptive method mix, as well as forecasting future needs;

• Reviewing commodity requirements annually for adjustments against the consumption pattern and current stock position;
• Ensuring timely procurement and delivery of contraceptives;

§  Managing warehousing, inventory control and proper distribution of contraceptive supplies to district stores/service delivery outlets managed by different stakeholders;

§  Computerizing the contraceptive logistics management information system for effective monitoring and to ensure implementation of the standard operating procedures (SOPs) of storage and distribution, as well as avoiding pilferage and wastage;

§  Upgrading warehousing facilities at the provincial and district levels, providing logistic support for the movement of stocks, and ensuring availability of trained workforce;

§  Supporting and encouraging the pharmaceutical sector to establish contraceptive commodity manufacturing units in the country;

§  Signing memoranda of understanding (MOUs) with the Ministry and Provincial Departments of Health and partners in social marketing for the purchase and distribution of contraceptives, medicines, equipment, etc; and

§  Developing a joint data management mechanism of all projects of the MoPW, MoH, NATPOW, SMCs and NGOs/CSOs advancing the FP/RH agenda.

e).  Training and Human Resource Development

The following measures would be adopted to boost the human resource development (HRD) efforts for ensuring effective implementation of the Programme:

§  Revamping and upgrading PWTIs and RTIs with modern facilities and professional staff, applying state-of-the-art methodologies and techniques;

§  Adopting standard-based management and recognition (SBMR) to institutionalize the quality of care;

§  Creating inter-linkages between research and training institutes to institutionalize research-based planning and training-backed interventions;

§  Incorporating reproductive health and family planning into the curricula of all medical colleges and universities; and

§  Developing HRD plans, both short-term and long-term, to institutionalize the appointment of right person to the right job.

f).  Research and Evaluation

§  Enabling NIPS and the NRIFC to provide up-to-date and reliable information to the policy planners, decision-makers and programmers in the field of population and development;

§  Strengthening NIPS as an autonomous research arm of the MoPW through appropriate legal framework. It would continue to serve as a technical body for policy research covering major aspects of reproductive health, family planning, fertility transition, population and development;

§  Upgrading the NRIFC to institutionalize research based-planning, and repositioning it to work on clinical studies, bio-medical research, and testing of the existing and new family planning methods;

§  Encouraging collaboration of NIPS and the NRIFC with national and international academic and research organizations to support demographic and clinical research in Pakistan. NIPS would specifically focus on the analysis of the key interrelationships between determinants of fertility transition and critical indicators;

§  Focusing on Pakistan-specific research in the areas that have a clear link with population: health, morbidity, mortality, etc.; and

§  Conducting research on the socio-cultural determinants of fertility behaviour, especially at the household and individual levels, as well as the changing age structure, youth bulge, population ageing, urbanization and migration to reap the demographic dividend in the shortest possible timeframe.

g).  Public-Private Partnership

The focus of the strategy would be on extending the outreach of FP/RH services, to rural areas and urban slums through public-private partnerships (PPPs). Some of the activities to be undertaken include the following:

§  Strengthening NATPOW to institutionalize and catalyse PPPs for broadening networking;

• Expanding cooperation for the expansion of FP/RH services through the network of about 13,000 service outlets of the Ministry and Provincial Departments of Health;
• Strengthening partnership with public sector organizations and corporate bodies:

o   Peoples’ Primary Health Initiative: through the existing 3,000 outlets

o   Provincial Line Departments: through their existing health outlets (1,000)

o   Corporate Sector: through the existing 6,000 health outlets

§  Establishing community partnership for setting up FHHs at the village level (1,000-3,000 house holds);

• Providing budgetary support to the SMCs working in rural areas and urban slums;
• Expanding the social marketing network to rural areas by franchising SMCs; and
• Establishing an independent body for regulating the resources and performance of SMCs and other private sector institutions working in the areas of reproductive health and family planning.

h).  Monitoring

• Creating a joint forum for carrying out strategic monitoring to ensure effective implementation of the Programme by all the stakeholders;
• Developing necessary indicators on the basis of priority monitoring and evaluation areas. Since the implementation of the Policy 2010 involves many ministries and departments, they would apply these indicators accordingly to track their progress;
• Compiling district profiles, and carrying out community need assessments, sample studies and client satisfaction surveys;
• Carrying out operational monitoring by the tehsil, district and divisional tiers and taking immediate remedial and follow up action at the monthly/quarterly meetings;
• Reviewing of the monitoring reports of the district and divisional tiers by the Provincial Population Welfare Departments; and
• Analyzing consolidated monitoring reports by the MoPW to carry out monitoring of the monitors and service delivery centres by a mixed team on 10 percent random sample basis.

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