63071 Fertility Decline in Pakistan 1980–2006 A Case Study The World Bank May 2010 Fertility Decline in Pakistan 1980–2006 A case study May 2010 iii contents Acknowledgments vi Abbreviations vii Executive summary viii Introduction 1 Political, Economic, and social Progress has been uneven 2 Fertility transition and current Fertility status — Good but Inconsistent Progress 4 Four Proximate Determinants of Fertility in Pakistan — Differing Effects on Fertility 6 Marriage and sexual union 6 use of contraceptives 7 Induced abortions 10 Duration of breastfeeding 11 socio-Economic and cultural Factors Influencing Fertility in Pakistan 12 child Mortality and Desired family size and composition 12 female education 13 Women’s labor for participation and autonomy 15 Religion and Religious leadership 16 Role of Men and spousal communication 16 Government Population Policy and the Family Planning service Provision — An Early but slow start 18 Institutional structure of the family planning service provision system 19 The government sector service Delivery system for family planning 20 Role of the private sector and nongovernmental organizations 20 status of the family planning services 21 government financing of population programs 22 iv Pakistan’s Innovative Family Planning Programs 24 Innovations in government family planning programs 24 Innovations in ngo and private sector programs supported by Donors 25 Implications 29 Annexes annex 1. evaluation of the lady Health Worker program 30 annex 2. country-at-a-glance: pakistan 32 References 34 Endnotes 39 Figures figure 1. Map of pakistan x figure 2. Total fertility Rate in pakistan, 1984–2000 5 figure 3. Total fertility Rate and contraceptive prevalence Rate in pakistan, 1984–2005 8 figure 4. use of Modern contraceptive Methods in pakistan, 1990–91 and 2006–07 9 figure 5. Infant Mortality Rate in south asian countries, 1980–2005 (per 1,000 live births) 13 figure 6. government spending (federal and provincial) on population and Health, 1987–2006 (Millions of Rupees) 23 tables Table 1. socioeconomic Indicators in south asian countries, circa 2005 3 Table 2. progress Toward Health-Related Millennium Development goal Targets in pakistan 3 Table 3. changes in singulate Mean age at Marriage in pakistan, selected Years, 1951–2003 7 Table 4. contraceptive Methods used by currently Married Women ages 15–49 by background characteristics 9 Table 5. literacy Rates in pakistan by gender, locale, and province (ages 10 and older), 1981–2007 14 fertility Decline in pakistan, 1980–2006 | a case study v Table 6. government expenditure on population and Health and average annual growth, 1990/91–2005/06 (percent) 23 Table 7. Trend in Total fertility Rate and contraceptive prevalence Rate During 1990s 28 boxes box 1. Role of International Donors 26 box 2. World bank assistance to the population sector in pakistan 27 vi Acknowledgments t his report was prepared by Naoko Ohno Action International), Daniel Kraushaar (Bill of the Health, Nutrition and Popula- and Melinda Gates Foundation), Gilda Sedgh tion unit of the South Asia region at (Guttmacher Institute), Amy Tsui (Johns Hop- the World Bank (SASHN), Sadia Chowd- kins University, Bloomberg School of Public hury of the Health, Nutrition, and Popu- Health), and Wasim Zaman (International lation unit of the Human Development Council on Management of Population Pro- Network (HDNHE), Inaam Haq (SASHN), grammes). The World Bank advisory group and Mehtab S Karim, previously at Aga Khan comprised: Martha Ainsworth (IEGWB), Peter University, Karachi and presently at School of Berman (HDNHE), Eduard Bos (HDNHE), Public Policy, George Mason University. Rodolfo Bulatao (HDNHE), Hugo Diaz The Population Council, Pakistan is grate- Etchevere (HDNVP), Rama Lakshminaray- fully acknowledged for providing pertinent anan (HDNHE), John May (AFTHE), Eliz- background articles. The authors are grateful abeth Lule (AFTQK), and Thomas Merrick to the World Bank Library Research Services (WBIHS). for assisting with the literature search. Mukesh Bruce Ross-Larson, Communications De- Chawla, Sector Manager (HDNHE), and Ju- velopment Incorporated, edited the draft report lian Schweitzer, Sector Director (HDNHE), and Samuel Mills (HDNHE) reviewed the final provided overall guidance and support. draft. The authors would like to thank the gov- Thanks to Victoriano Arias (HDNHE) for ernment of the Netherlands, which provided providing administrative support. financial support through the World Bank- This case study was part of a larger World Netherlands Partnership Program (BNPP). Bank Economic and Sector Work entitled Ad- dressing the Neglected MDG: World Bank Re- Correspondence Details: view of Population and High Fertility with an external advisory group comprising: Stan Bern- Æ Sadia Chowdhury (HDNHE), World stein (United Nations Population Fund), John Bank, Mail Stop G7–701, 1818 H Street Bongaarts (Population Council), John Cast- N.W., Washington, DC 20433, USA, Tel: erline (Ohio State University), Barbara Crane 202-458-1984, email: schowdhury3@ (IPAS), Adrienne Germain (International worldbank.org Women’s Health Coalition), Jean Pierre Guen- Æ This report is available on the following gant (L’Institut de recherché pour le dével- website: oppement), Jose Guzman (United Nations http://www.worldbank.org/hnppublica- Population Fund), Karen Hardee (Population tions. fertility Decline in pakistan, 1980–2006 | a case study vii Abbreviations AFTHE Health, Nutrition, and IUD Intrauterine device Population unit of the Africa KfW German development bank region KSM Key Social Marketing AFTQK Africa Operational Quality and LHWP Lady Health Worker Program Knowledge Services MDG Millennium Development Goal GNI Gross national income NWFP North West Frontier Province GSMP Greenstar Social Marketing PAVHNA Pakistan Voluntary Health and Pakistan Nutrition Association HDNHE Human Development SAP Social Action Program Network, Health,Nutrition, SAPP Social Action Program Project and Population unit SMP Social Marketing Pakistan HDNVP Office of the Senior Vice VBFPW Village-Based Family Planning President and Head of Human Worker scheme Development Network WBIHS World Bank Institute Health IEGWB Independent Evaluation Systems Group, World Bank viii Executive summary P akistan is the world’s sixth most popu- and contraceptive use, with induced abortions lous country and has the second largest perhaps also contributing. Key sociocultural Muslim population after Indonesia. contributors include smaller desired family Since independence in 1947, Pakistan’s tur- size, greater female education and labor force bulent political situation has frequently dis- participation, and better spousal communica- rupted government development policies. tion, with obstacles to fertility decline being Health status has improved since 1990, but opposition to family planning by some reli- the pace of improvement has been slow and gious leaders, husbands, and their mothers; performance lags behind other South Asian women’s low social status; and cultural prohi- countries. Large gender disparities persist in bitions, such as, on women’s travel alone out- education and health status, as well as in ac- side the home. cess to employment, assets, and justice. Government and private sector family Unlike in the other four case study coun- planning programs also contributed to the de- tries (Algeria, Botswana, Iran, and Nicaragua), cline. Two innovative population programs the history of fertility reduction in Pakistan begun in the 1990s are especially noteworthy. has not been a story of unbroken successes but Large-scale community-based programs rather one of incomplete responses and short- (the Village-Based Family Planning Worker comings mingled with successes that offer les- scheme and the Lady Health Worker Pro- sons for other high-fertility countries. The gram) brought family planning services to total fertility rate in Pakistan stood at over women’s doorsteps as it became clear that an estimated 6.5 from the 1960s to the late geographic and socio-cultural constraints on 1980s, when the fertility rate started to decline women were resulting in underuse of services rapidly until 2000, when the decline seems to provided in fixed facilities. And private sector have stalled. Estimates of the current total fer- involvement in family planning began in the tility rate vary from 3.8 to 4.1, roughly a 40 1980s with the Greenstar Network of social percent decline since the 1980s. Contraceptive marketing of contraceptives, which now pro- prevalence also rose, from 12 percent in 1990 vides 30 percent of modern contraceptives to 30 percent in 2006, but since then, has re- used in Pakistan, making it the second largest mained stagnant. family planning service provider after the gov- Several factors appear to have contributed ernment. to the decline in fertility in Pakistan. Among During the 1990s, family planning ser- the proximate determinants are the propor- vices improved and contraceptive prevalence tion of women married (later age at marriage) rates more than doubled, likely contributing fertility Decline in pakistan, 1980–2006 | a case study ix to the decline in the total fertility rate over reduced the effectiveness of population pro- that period. However, the programs have con- grams. The government needs to address these siderable room for improvement, and Pakistan underlying constraints and program short- has made little progress in reducing socio-cul- comings to meet the high level of unmet de- tural constraints to family planning related to mand for contraceptives if it is to accelerate religion, gender, and locale, which likely have and sustain fertility reduction. x Figure 1 | Map of Pakistan source: World bank Map Design unit. fertility Decline in pakistan, 1980–2006 | a case study 1 Introduction P akistan was selected as a case study be- study countries (Algeria, Botswana, Iran, and cause of its estimated 40 percent decline Nicaragua), the history of fertility reduction in in fertility between 1980 and 2006. Pak- Pakistan has not been an overwhelming suc- istan’s high fertility rate began to decline grad- cess story but rather a story of challenges, par- ually after the late 1980s and has continued to tial responses, and shortcomings that offer fall since then, though progress has been un- abundant lessons for other high-fertility coun- even and there have been signs of a slowdown tries as well as planners in Pakistan. in recent years. Unlike the other four case 2 Political, Economic, and social Progress has been uneven P akistan is the world’s sixth most popu- dent policies and declining international sup- lous country (its 2009 population is es- port because of Pakistan’s nuclear program timated as 171 million by Ministry of led to an economic slowdown in the 1990s. Population Welfare, Government of Pakistan, Average annual growth stagnated at around and 181 million by the United Nations Pop- 4 percent over the 1990s, contributing to a ulation, Division), with a gross national in- rapid increase in poverty. Falling tax reve- come (GNI) per capita of US$800 in 2006.1 nues limited the government’s ability to pro- Some 97 percent of the population is Muslim. vide critical social services. Fiscal deficits were Pakistan is a federation of four provinces— high throughout most of the 1990s, adding to Balochistan (the largest, but with just 5 per- rising public sector indebtedness. Poverty gaps cent of the population), North West Frontier across regions and provinces persisted or wid- Province (NWFP, with 13 percent), Punjab ened. During the first five years of 2000, wide- (with 56 percent), and Sindh (23 percent)— ranging economic reforms and a shifting of the and four territories—Islamabad Capital Ter- international political environment resulted in ritory, federally administrated tribal areas, a stronger economic outlook and accelerated Azad Jammu and Kashmir, and federally ad- growth, especially in manufacturing and finan- ministered Northern Areas. Azad Jammu and cial services. However, the current global eco- Kashmir is semiautonomous but indirectly nomic crisis, with rising food and oil prices, administered by the government of Pakistan has slowed economic growth and threatens to as separate political entity while, federally ad- reverse the declining trend in poverty. ministered Northern Areas, has recently been Human development has long been ne- given the status of a province. glected in Pakistan. While health status has Since independence in 1947, Pakistan improved since the 1990s, the rate of im- has had a turbulent political history, with re- provement has been slow, and performance peated coups impeding the maturation of po- lags behind South Asian countries (table 1). litical institutions and democracy, interrupting Gender disparities persist in education and development efforts, and delaying social health outcomes as well as in employment, as- development and the emergence of a market sets, and justice because of unequal access to economy. opportunities and services. After rapid economic growth in the 1970s As a result, Pakistan has made only slow to 1980s that sharply reduced poverty, impru- progress toward the Millennium Development fertility Decline in pakistan, 1980–2006 | a case study 3 table 1 | socioeconomic Indicators in south Asian countries, circa 2005 under-five births attended Life expectancy mortality rate by skilled staff total fertility GNI per capita at birth, female (per 1,000 live (percentage of rate country (us$) (years) births) births) (per woman) pakistan 860 66 90 39 4.0 bangladesh 470 65 60 18 2.9 India 950 66 72 47 2.7 nepal 350 64 55 19 3.1 sri lanka 1540 76 20 98 1.9 source: World bank 2006, 2007. Goal targets, although there has been steady tion coverage and births attended by skilled improvement in recent years. While under-five staff, have improved considerably. The gov- and infant mortality rates have fallen, Paki- ernment has committed to achieving the Mil- stan, like most South Asian countries, made lennium Development Goal targets, but to little progress in reversing child malnutrition accelerate progress to reach the targets, sub- in the 1990s. Improvement in the maternal stantial additional resources and effort will be mortality ratio has also been slow. However, required. health service indicators, such as immuniza- table 2 | Progress toward health-Related Millennium Development Goal targets in Pakistan 1990 or 2005 or target and indicator 1991 2006 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate under-five mortality rate (per 1,000 live births) 130 97 Infant mortality rate 100 78 percent of children 12–23 months immunized against measles 50 80 Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Maternal mortality ratio (per 100,000 live births) 340 320 percent of births attended by skilled health staff 19 31 source: united nations Millennium Development goals Indicators database (http://mdgs.un.org/unsd/mdg/Data.aspx) March 25, 2009. 4 Fertility transition and current Fertility status — Good but Inconsistent Progress I n the late 1980s, the fertility rate began to suggests that surveys based on birth histo- decline in Pakistan after a long period of ries, such as the Pakistan Demographic and sustained high fertility, dropping by 40 per- Health Survey 1990−91 and the 1997 Paki- cent over the past two decades. The history of stan Fertility Family Planning Survey, un- population policies and outcomes in Pakistan derestimated the total fertility rate.6 Many is not one of unqualified success, however, but demographers disputed the fertility rate of rather a series of challenges, advances, and set- 5.5 estimated by the Pakistan Demographic backs. There are abundant lessons for high-fer- and Health Survey 1990−91, especially in tility countries in Pakistan’s experience. This light of the low 12 percent contraceptive case study highlights likely factors that have prevalence rate at the time. influenced fertility change in Pakistan. Demographers tend to agree on the late The total fertility rate was more than 6 1980s as the onset of the fertility decline. children per woman until the 1980s.2 Survey Some argue that it began between 1987 and estimates show the rate falling below 6 chil- 1988 and lasted until at least 2000, based dren for the first time during the 1990s and on Pakistan Demographic Survey data.7 This declining consistently until the 2000s.3 The position is supported by estimates from the latest Pakistan Demographic and Health 1998 Census and the 2000−01 Pakistan Re- Survey, for 2006−07, shows a total fertility productive Health and Family Planning rate of 4.1 children in 2004−06, and the rate Survey. Another study argued that the onset appears to have stalled more recently. A de- was probably in the early 1990s or in the late cline of 1.8 children per woman per decade, 1980s, noting that data from the 1990s ex- based on the estimates from the Pakistan De- hibit a clear decline in fertility levels and that mographic Survey, is remarkably fast com- estimates imply a modest decline of around pared with the decline of 1.5 for East and one birth per woman between 1980s and the Southeast Asian countries.4 1990s.8 The Pakistan Demographic Survey Surveys provide varying estimates of the data show a decline after the late 1980s fertility rate.5 A 2003 analysis of survey data (figure 2). fertility Decline in pakistan, 1980–2006 | a case study 5 Figure 2 | total Fertility Rate in Pakistan, 1984–2000 8 6.9 7 6.9 6.9 7 6.5 6.4 % of children per woman 6.2 6 5.8 5.7 6 5.6 5.6 5.5 5 4.8 5 4.5 4.3 4.1 3.9 3.8 4 3 2 1 0 1985 1986 1988 1989 1990 1993 1995 1996 1998 1999 1984 1991 1992 1994 2003 2005 1987 2000 2001 1997 Year source: for 1984−2000, pakistan Demographic survey from feeney and alam 2003a; for 2001, 2003, and 2005, pakistan Demographic survey. 6 Four Proximate Determinants of Fertility in Pakistan — Differing Effects on Fertility t his section reviews the literature on four and proportion of women never married at proximate determinants of fertility in age 15–19 likely played a key role in fertility Pakistan: proportion of women mar- decline.11 One research described “dramatic” ried; contraceptive prevalence rate; prevalence changes in marriage patterns. 12 The singu- of induced abortion; and duration of post- late mean age at marriage13 for women rose partum infecundability as measured by length from 20.2 in 1981 to 22.3 in 2003, and the of exclusive breastfeeding.9 According to two proportion of young women ages 15−19 who studies in 1994, of these four factors, the con- were never married rose from 71 percent to traceptive prevalence rate had the weakest ef- 87 percent (table 3). However, the data sug- fect on fertility reduction and postpartum gest that the largest rise in the female singu- infecundability the strongest.10 The effect of late mean age at marriage (a 3-year increase) induced abortion was not fully considered, and percentage of women never married ages however, because of a dearth of evidence on 15–19 (more than 40 percent increase) oc- abortions, which are illegal in Pakistan. Un- curred between 1961 and 1972, without trig- derestimating the effect of abortions likely gering any notable decline in the total fertility distorted the analysis of Pakistan’s fertility re- rate in the time period. duction, as the prevalence of induced abortion The median age at first birth for women appears to be notably high (see the section on ages 25−49 also shows a gradual rise, from induced abortion). Examination of other re- 20.3 in 1990−91 to 21.8 years in 2006−07.14 cent evidence suggests that age at marriage, While the overall increase is small, the largest contraceptive prevalence, and induced abor- increase occurred among women in the most tion contributed most to fertility reduction, fertile age group of 25−29 years (from age whereas postpartum infecundability was the 21.0 in 1990−91 to age 22.7 in 2006−07). least influential in case of Pakistan. Women’s education and family’s wealth levels are linked to the onset of childbearing; women Marriage and sexual union in higher education or higher wealth groups With contraceptive prevalence at a persis- delay childbearing for about 2 years. tently low rate in Pakistan, studies suggest The median birth interval in Pakistan that the rise in the age at marriage for women is 28.8 months, which shows a decline of fertility Decline in pakistan, 1980–2006 | a case study 7 table 3 | changes in singulate Mean Age at Marriage in Pakistan, selected Years, 1951–2003 singulate mean age at marriage (years)a Percentage of women Year Male Female never married, ages 15–19 1951 22.3 16.9 27.1 1961 23.3 16.7 25.4 1972 25.7 19.7 65.6 1981 25.1 20.2 70.6 1998 25.8 21.7 79.4 2003 26.4 22.3 86.6 source: sathar 2007, based on data from pakistan Demographic survey 2003. a. a measure comparing the age-specific proportions of women who have never been married with the age-specific propor- tions of those who have ever been married to calculate the mean age at which the transition between the two occurs. It is used to estimate mean age at marriage in countries where marriage records are absent or deficient. 0.3 month from 1990–91.15 It is consider- fertility rate decline. In Pakistan, when the ably shorter than in other South Asian coun- total fertility rate began to decline in the early tries such as India (31 months), Nepal (34 1990s, the contraceptive prevalence rate, months), Bangladesh (39 months), and Sri though low, was moving upward (figure 3). Lanka (52 months).16 The median birth in- Some researchers have argued that the rising terval is shorter if the previous child was a contraceptive prevalence rate among married girl (28.0 months) than if it was a boy (29.6 couples was the main reason for the fertility months), implying a persistent preference rate decline in the 1990s.17 for sons. Birth intervals are much shorter Several studies have examined the fac- if the previous child died (21.9 months) tors influencing the use of contraceptives in than if it survived (29.6 months). Birth in- Pakistan. Knowledge of contraceptives among tervals are shortest for women ages 15−19 ever and currently married women is al- (20.9 months). Women with the highest ed- most universal (96 percent), with knowledge ucation level have a slightly shorter interval greater for modern methods than for tradi- (28.0 months) than uneducated women (28.7 tional methods.18 Yet contraceptive use has re- months); there is little difference in the in- mained low. Further reducing the fertility rate terval length for rural (28.9 months) and in Pakistan requires understanding why the urban areas (28.7 months). In conclusion, high level of knowledge about family plan- birth intervals have changed little over time ning does not lead to greater use of family and therefore have likely not contributed di- planning. rectly to the fertility decline. Contraceptive prevalence rates among currently married women ages 15−49 hardly use of contraceptives changed until 1990, when the rate began to Higher contraceptive prevalence rates among rise. From a very low rate of 12 percent in women are an important contributor to the 1990−91, contraceptive prevalence more than 8 Figure 3 | total Fertility Rate and contraceptive Prevalence Rate in Pakistan, 1984–2005 8 35 Contraceptive prevalence (%) 7 30 6 25 TFR per woman 5 20 4 15 3 10 2 1 5 0 0 1984 1990 1994 1996 2000 2003 2005 Year TFR CPR note: Total fertility rate is calculated based on interviews with women ages 15−49; the contraceptive prevalence rate is based on currently married women in the same age group. source: Total fertility rate data from feeney and alam 2003a, based on data from pakistan Demographic surveys, and paki- stan Demographic survey 2003 and 2005; contraceptive prevalence rate data from pakistan Demographic and Health survey 2006−07 (national Institute of population studies and Macro International Inc. 2008). doubled by 2006–07 to 30 percent.19 There is common is female sterilization, followed by some indication of a plateau in recent years. condoms, intrauterine device (IUD)/inject- The most widely used method is female steril- ables, and oral contraceptives, especially among ization, followed by condoms, withdrawal, and women in rural areas, those in the poorest 20 the rhythm method. As expected, contracep- percent of the population, and those with no tive prevalence increases with a woman’s edu- education.21 For women in urban areas, in the cation level, wealth, and urban residence (table richest 20 percent, or with a higher educa- 4). Among currently married women, contra- tion, condoms are the most commonly used ceptive prevalence is highest in Punjab (33 per- method. By province, the most commonly used cent) and lowest in Balochistan (14 percent). modern methods are female sterilization and More than half of currently married women condoms in Punjab and Sindh, condoms and ages 15–49 either do not want another child withdrawal in NWFP, and oral contraceptives in the future or are sterilized. Demand for lim- and female sterilization in Balochistan. Women iting childbearing also has substantially risen opt for sterilization only after they have had from 40 percent in 1990–91 to 52 percent in many children (often five or more), so female 2006–07.20 Yet the rate of increase in contra- sterilization may not be a suitable option for ceptive use has remained slow. lowering the fertility rate. About three-quarters of current users em- Use of contraceptives increased in both ploy modern methods, a proportion unchanged rural and urban areas from 1990−91 to since 1990. Among modern methods, the most 2006−07 (figure 4).22 In urban areas, there was fertility Decline in pakistan, 1980–2006 | a case study 9 table 4 | contraceptive Methods used by currently Married women Ages 15–49 by background characteristics characteristic Any method Any modern method Residence urban 41.1 29.9 Rural 23.9 17.7 province balochistan 14.4 13.4 nWfp 24.9 18.7 punjab 33.2 23.1 sindh 26.7 22.0 education none 25.3 18.9 Higher 42.6 31.4 Wealth poorest 20 percent 15.6 12.4 Richest 20 percent 43.4 31.6 Total 29.6 21.7 source: pakistan Demographic and Health survey 2006−07 (national Institute of population studies and Macro International Inc. 2008). Figure 4 | use of Modern contraceptive Methods in Pakistan, 1990–91 and 2006–07 50 45 40 35 30 Percent 25 20 15 10 5 0 1990–91 2006–07 1990–91 2006–07 1990–91 2006–07 1990–91 2006–07 1990–91 2006–07 1990–91 2006–07 Any Any modern Female Pill Condom IUD method method sterilization Type of contraceptive methods Major cities Total urban Rural source: pakistan Demographic and Health survey 2006−07 (national Institute of population studies and Macro International Inc. 2008). 10 a slight increase in female sterilization, a large rate could be even higher, as the reported level increase in oral contraceptive and condom of miscarriage is high at 8.1 percent, which use, and no major change in the use of the might have included some induced abortions. IUD. The increase in oral contraceptive and Estimates in the published literature vary. condom use could reflect the impact of social One nationwide study, using the medium es- marketing projects in urban areas (see section timate of 35 percent of late term spontaneous on innovations in family planning programs). abortions treated in a hospital estimates that In rural areas, there was a large increase in ac- 890,000 induced abortions are performed an- ceptance of modern methods, especially fe- nually in Pakistan for a national annual in- male sterilization, oral contraceptive, and duced abortion rate of 29 per 1,000 women condom use. ages 15–49 (2.9 percent).28 Another study es- Despite the rise in contraceptive use since timated the abortion rate at 4.1 percent from the 1990s, Pakistan faces a high level of unmet a sample of 1,214 women in low-income need—25 percent among currently married squatter settlements of Karachi.29 Unplanned women.23 That is comparable to rates in Sub- and mistimed pregnancies due to ineffec- Sahara African countries and, in Asia, to rates tive use of contraceptives and high unmet in Nepal (24.6 percent) and Cambodia (25.1 need are the main reasons women reported percent).24 In India, the unmet need is lower, choosing induced abortion. at 13 percent.25 Use of contraceptives by The aforementioned nationwide study es- women is affected by such factors as husband’s timated an abortion ratio of 14 per 100 preg- approval, religious belief, fear of side effects, nancies, meaning that a surprisingly high one lack of access to services, poor communication in seven pregnancies is terminated by induced between spouses, mother-in-law’s influence, abortion in Pakistan.30 This finding implies and cost (see section on socioeconomic and that induced abortions might have greatly in- cultural factors),26 all factors that could be ad- fluenced fertility levels. The study found a dressed with the proper strategies. relationship between the level of contracep- tive use and the level of abortions, with esti- Induced Abortions mated abortion rates higher in provinces with Termination of pregnancy is illegal in Paki- lower contraceptive prevalence rates (NWFP stan, except to save the mother’s life. How- and Balochistan). Though the study used the ever, considering the low contraceptive medium-level estimate, the rates may be un- prevalence rate, the high unmet contracep- derestimated because they are based on esti- tive need, and the strong desire to limit child- mated post-abortion hospitalizations, and the bearing, it can be assumed that many women survey did not include private sector facilities in Pakistan are at risk of an unwanted preg- or public primary health care centers. nancy and induced abortion. Although it is Poverty and already having the desired difficult to get an accurate figure because in- number of children are the most common rea- duced abortions are illegal, 1.5 percent of sons reported by women seeking abortions. ever-married women are estimated to have In one study, 20 percent of respondents re- experienced induced abortions.27 The actual ported contraceptive failure (mostly tradi- fertility Decline in pakistan, 1980–2006 | a case study 11 tional methods) as the main reason. These hospitals in order to avoid such treatment seek findings suggest that women face difficulty ob- unsafe abortions from unskilled abortionists taining reliable family planning methods and and traditional healers. use abortion as a back-up method to termi- nate unintended pregnancies.31 Duration of breastfeeding One study in six tertiary hospitals in Breastfeeding likely has had little if any impact Karachi, Lahore, and Peshawar found that on fertility reduction in Pakistan. Following more than 90 percent of staff in the depart- childbirth, the median duration of amenor- ments of obstetrics and gynecology had en- rhea is 3.9 months, abstinence 2.1 months, countered abortion cases one month prior to and women’s insusceptibility an estimated 4.8 the survey.32 More than half were due to un- months.33 The median duration of exclusive wanted pregnancy and a quarter to contra- breastfeeding is only 3.2 months, and less than ceptive failure. Most health care providers a quarter of newborns below age six months (87 percent) looked unfavorably on induced are exclusively breastfed. Postpartum absti- abortion, and their religious beliefs were sig- nence extends to 40 days after birth according nificantly associated with the practices. Physi- to the Muslim tradition. Thus the major de- cians believed that sharp curettage was more terminant of the length of insusceptibility common, though vacuum aspiration is safer is likely amenorrhea. Amenorrhea is longer and less expensive. Contraceptive counseling among women in rural areas (5.1 months) services following abortion are often missing. than urban areas (4.1 months), among poor Thus, patients seeking abortion-related ser- women (4.4 months) than rich (2.8 months), vices may receive insufficient or inappropriate and among women with no education (4.4 treatment from health professionals. Often, months) than women with a secondary educa- women who decide not to go to government tion (2.4 months). 12 socio-Economic and cultural Factors Influencing Fertility in Pakistan M any socioeconomic and cultural factors to 78 per 1,000 live births and in the under- influence fertility in Pakistan, particu- five mortality rate from 117 to 94 per 1,000 larly child mortality, female education, live births.34 More than half the reported women’s labor market participation, religion, deaths in children under five occur during and the influence of husbands and spousal the neonatal period. Mother’s education and communication. wealth, birth intervals, and residence are highly correlated with child mortality. One child Mortality and Desired Family study found that mother’s education, breast- size and composition feeding, place of delivery, and prenatal care Pakistan’s infant mortality rate and under- were the most important factors affecting five mortality rate have gradually declined, child mortality risk.35 but improvement has been slow compared A desire to limit additional children is with that in neighboring South Asian coun- strongly associated with the number of a tries and threatens achievement of the Mil- woman’s living children, reaching 55 percent lennium Development Goal targets in child among women with three children and 88 health. Bangladesh and Nepal, which had a percent among those with six or more. The much higher infant mortality rate than Paki- desire to limit childbearing has been rising in stan in 1980, have made remarkable progress, Pakistan, from 40 percent of currently mar- lowering infant mortality rates to 40 percent ried women in 1990−91 to 52 percent in of their 1980 levels (figure 5). India, whose 2006−07.36 Women with higher education, in infant mortality rate in 1980 was similar to the wealthiest 20 percent, and living in urban Pakistan’s, has also made steady progress, and areas have the lowest desire for additional its rate today is considerably lower than Paki- children. stan’s. While reduced child mortality is known The mean ideal number of children to have an impact on declining fertility, it is is 4.1 for ever-married and currently mar- unclear to what extent this slow change in ried women, a number unchanged since child mortality has affected desired fertility in 1990−91.37 The mean ideal number of chil- Pakistan. dren is lowest in Punjab (3.8) and highest in Other data, though differing slightly NWFP (5.9). Many women have more chil- from those in figure 4, also show a gradual dren than they would prefer; 54 percent of decline in the infant mortality rate from 91 women with six or more children have ex- fertility Decline in pakistan, 1980–2006 | a case study 13 Figure 5 | Infantbirths) Rate in south Asian countries, 1980–2005 (per 1,000 Live Mortality 140 120 per 1000 live births 100 80 60 40 20 0 1980 1985 1990 1995 2000 2005 Bangladesh India Malvides Nepal Pakistan Sri Lanka source: World bank, various years, World Development Indicators. ceeded their ideal family size, as have 52 per- sons and one or more surviving daughters. cent of those with five children. Bearing sons is a way for women to increase Desired family size is closely associated their status. with the desire for sons in Pakistan and other Husbands and mothers-in-law also af- South Asian countries, where there is a strong fect women’s desire for family planning, with preference for sons.38 In in-depth interviews negative impacts on family size. Opposition in a study of low-income women in Punjab, to family planning by mothers-in-law stems women expressed a strong son preference, from a desire for more grandchildren, es- mostly for economic reasons, reflecting wom- pecially sons, and the traditional belief that en’s subordinate social status and the low eco- Islam forbids family planning.41 About half nomic value placed on women’s work.39 In the women in an urban slum study reside some rural areas, especially in Punjab, raising with their mother-in-law, so that negative at- daughters is too costly because of the need for titudes from both husband and mother-in- a dowry. Among Pakistani women with three law may be a formidable barrier to the use of children, 65 percent of those with three sons contraceptives.42 want no more children compared with only 14 percent of those with three daughters. A Female Education longitudinal study in an urban slum in Ka- Female education, by increasing a woman’s rachi found that the sex of surviving children, knowledge and ability to make independent particularly the number of sons, is associated decisions, is likely to contribute to lower fer- with unwanted pregnancies and influences tility.43 Both proximate determinants of fer- subsequent reproductive behavior.40 The study tility, such as age at marriage and use of reports a marked increase in contraceptive use contraceptives, and socioeconomic and cul- among women with two or more surviving tural factors, such as child mortality and 14 spousal communication, are highly correlated only a quarter of women have a primary edu- with a woman’s educational attainment. cation, and more than half of women have re- Though long neglected, women’s educa- ceived no education.45 tion has gradually been improving (table 5). Expansion of female higher education has The female literacy rate nearly tripled, from a significant impact on fertility by delaying 16 percent in 1981 to 42 percent in 2006−07, marriage and birth of the first child. Pakistan and the rural-urban literacy gap shrank from needs to promote universal primary educa- about 1:5 to 1:2. The female literacy rate is tion first as a pathway to moving up to sec- highest in Punjab (46.4 percent) and lowest ondary and higher education for women. in Balochistan (23.3 percent). But the gap be- International evidence shows that female pri- tween rural Balochistan women (15.7 percent) mary education also lowers the fertility rate, and urban Punjab women (64.3 percent) is though the net effect is only a third that for quite wide (1:4). secondary school.46 Among the constraints to The rural-urban gap also exists for pri- female primary enrollment are distance from mary and secondary schooling. The primary school, especially in rural areas (schools are school enrollment rate for girls is 45.5 per- overwhelmingly located in wealthier commu- cent, but 64.6 percent for urban girls and 39.3 nities); school expenses, parents’ reluctance to percent for rural girls. Similarly, the secondary educate girls, and scarcity of female teachers.47 school enrollment rate is 27.1 percent, but A study in rural communities in Punjab 49.5 percent for urban girls and 17.3 percent and NWFP found that the accessibility and for rural girls.44 quality of public primary schools within the While the proportion of women with a community positively influenced the fertility secondary or higher education has doubled transition in rural Pakistan.48 The study esti- among women of reproductive age, less than mated that gender equity in primary school half of girls are enrolled in primary school, access in rural Pakistan could lead to a 14–15 table 5 | Literacy1981–2007Pakistan by Gender, Locale, and Province (Ages 10 and older), Rates in 2006–07 Labor Force 1981 census 1998 census survey characteristic total Male Female total Male Female total Male Female pakistan 26.17 35.05 15.99 43.92 54.81 32.02 55.0 67.0 42.4 Rural 17.33 26.24 7.33 33.64 46.38 20.09 46.2 60.8 31.2 urban 47.12 55.32 37.27 63.08 70.00 55.16 71.1 78.2 63.5 balochistan 10.32 15.20 4.32 24.83 34.03 14.09 44.0 61.1 23.3 nWfp 16.70 25.85 6.48 35.41 51.39 18.82 49.0 68.5 30.2 punjab 27.42 36.82 16.81 46.56 57.20 35.10 56.1 65.7 46.4 sindh 31.45 39.74 21.64 45.29 54.50 34.78 57.6 70.2 43.4 source: census data (www.statpak.gov.pk/depts/pco/statistics/other_tables/literacy_ratio.pdf) and 2006–07 labor force survey (pakistan federal bureau of statistics). July 2008. fertility Decline in pakistan, 1980–2006 | a case study 15 percent increase in the probability of contra- The relationship between women’s labor ceptive use. The study emphasized the impor- participation, decision-making power, and re- tance of triggering demand for fertility change productive behavior is complex in Pakistan. through opportunities for investing in the Use of any contraceptive method is highest schooling of boys and girls and of bringing eq- among women who worked only after mar- uity to the supply of girls’ primary schools, vil- riage (38 percent) or who never worked (30 lage by village. percent) and lowest among currently working women (29.2 percent).52 women’s Labor for Participation A multivariate analysis shows that wom- and Autonomy en’s increased participation in household deci- Women’s status has an important influence on sion-making positively is associated with lower fertility rates, though the relationship is par- fertility outcomes, though it is strongly con- ticularly complex in Pakistan. Women’s status ditioned by socio-economic and demographic is extremely low in Pakistan, which ranks factors.53 The study also found a strong posi- 126 out of 128 countries on the Gender Gap tive link between women’s freedom to travel Index as measured by education (123rd), op- outside the home alone and their domestic portunities for economic participation (126th), decision-making power, especially in rural health and survival (121st), and political em- areas. The study concluded that good spousal powerment (43rd).49 communication had a strong effect on contra- In Pakistan, opportunities for women ceptive use and desired childbearing for both to work in the formal sector are limited. rural and urban women. Only 19 percent of women older than age Another study confirmed the ambiguous 10 are employed in the formal sector, about relationship between women’s labor partici- a quarter of the rate for men (70 percent).50 pation and autonomy.54 It found that rural Adding informal sector employment more women’s earned income had no effect on deci- than doubles women’s labor force participa- sions such as use of family planning. In con- tion (41 percent), which has risen rapidly trast, a study of women in northern Punjab since 2001−02 (26 percent).51 The highest concluded that women’s work (especially paid rate is reported for NWFP (56 percent), fol- employment), age, and family structure ap- lowed by Balochistan (49 percent); women’s pear to be linked to women’s increased de- participation is lowest in Sindh (36 percent). cision-making power and autonomy in the About 20 percent of women in the informal household.55 It found that Northern Punjabi sector are unpaid family workers. Labor force women have less economic autonomy but participation is highest among women with greater mobility and decision-making power no education or with a secondary or higher than women in Southern Punjab. level of education. Women with no educa- A study based on interviews with 1,842 tion and in rural areas are likely to be engaged married women in India and 1,036 in Paki- in unpaid work, while women in urban areas stan found that region of residence also plays and with a higher level of education tend to a major conditioning role after controlling for be engaged in paid work. religion and that the influence of traditional 16 factors conferring status on women remained in other Muslim countries, were proposed as strong.56 Women’s education and employ- one way to change attitudes among religious ment were not found to enhance women’s au- leaders. tonomy. The study emphasized the need for context-specific and comprehensive strategies Role of Men and spousal to enhance women’s autonomy beyond edu- communication cation, employment, and delayed marriage, In Pakistan, where women are generally sub- such as enabling women to mobilize and ac- ordinate to men, studies repeatedly identify cess community resources and public services the husband’s agreement as one of the most and providing support to challenge traditional influential determinants of the acceptance norms. of family planning in both rural and urban areas.60 A study in Naushahro Feroze District, Religion and Religious Leadership Sindh, using multivariate analysis found that Pakistan’s main religion, Islam, strongly influ- use of family planning is five times more likely ences family planning. Although Islamic scrip- if a woman receives her husband’s approval.61 tures do not proscribe family planning57, most Another study in an urban slum found that religious parties and many religious leaders women were 10 times more likely to use oppose it. family planning methods if their husband ap- Most respondents in a study of religious proves.62 influence on attitudes toward family planning Related to the notion of a husband’s ap- said that while they did not know whether proval of family planning is the importance Islam permits use of contraception, they be- of good spousal communication, something lieve that Islam opposes the norm of small many studies find lacking in Pakistan.63 One families and use of family planning to space study revealed that women believed their hus- births.58 The main reason given by married bands to have more negative views toward women for not using contraception was that family planning than was true, highlighting having children is “up to God.” The study the value of spousal communication to dispel concluded that the high degree of fatalism such misperceptions.64 Another study found underlying such thinking and the belief that a strong positive relationship between spousal Islam prohibits family planning are behind the communication and contraceptive use or de- high fertility levels in Pakistan. sired family size for both urban and rural A study in rural Pakistan found that women.65 most men (89 percent) believed that religious To make sound decisions, husbands need leaders opposed fertility control.59 Respon- information about women’s reproductive dents suggested that religious leaders must health, yet many family planning programs be involved if reproductive health programs are directed only to women. There are miscon- are to be effective in rural areas. Information ceptions and large gaps in knowledge among programs explaining that the Qur’an and Ha- men on a range of reproductive health is- dith are not against fertility control, along sues. One study found that 93 percent of men with examples of family planning programs wanted more information on family planning fertility Decline in pakistan, 1980–2006 | a case study 17 and showed a willingness to become partners demand for family planning and gaps in the in their wife’s reproductive health.66 A rising availability and quality of family planning ser- share of Pakistani men is strongly motivated vices.69 In addition, withdrawal seems to be to fulfill their family’s fertility preferences widely accepted because of fear of modern through contraceptive use.67 contraceptive methods and their side effects As further evidence of husbands’ will- and strong religious beliefs that other methods ingness to engage in family planning, half of are prohibited.70 Because withdrawal has a couples nationwide practicing family plan- high failure rate, however, it remains critical to ning use methods that require male coopera- increase knowledge about contraceptives and tion (condom, rhythm, and withdrawal).68 their side effects and to make a wide range of The rising use of withdrawal reflects growing contraceptive methods available. 18 Government Population Policy and the Family Planning service Provision — An Early but slow start P akistan was one of the first countries traceptives, mounting advocacy campaigns, to acknowledge the negative impact targeting underserved groups, introducing of rapid population growth on eco- a cadre of male mobilizers, improving mo- nomic and social development, as noted in bile service units, building population-cen- its first Five-Year Plan of 1955−60. Each tered services, involving the private sector successive plan has continued to do so, em- and nongovernmental organizations (NGOs), phasizing the need to control population strengthening collaboration among ministries growth through family planning programs. and departments, and decentralizing manage- Follow-up lagged, however, likely reflecting ment to provinces and districts. the lack of political commitment. A critical Despite the early recognition of popula- limitation of Pakistan’s population policy, tion issues, political support and commitment according to one study, is that it failed to has been inconsistent, undermining imple- comprehensively define a program linking mentation.73 Family planning policies fell development efforts and population plan- victim to divisive domestic politics, resulting ning.71 A review of population policies since in inadequate budget allocations and hesita- the 1960s concluded that no significant tion by the international community to sup- gains have been made toward the targets de- port family planning activities. President Ayub fined in various plans, because population Khan (1958−69) was the first head of state was not integrated into the development to publicly address the need for family plan- planning process and so the pressures it ning despite strong opposition from religious would exert on social and economic sectors leaders. But later presidents relegated family were not taken into account.72 planning programs to the background, espe- Pakistan’s first population policy, an- cially Muhammad Zia ul-Haq (1977–88), nounced in 2002, saw fertility reduction as whose support base was led by the conser- part of a wider poverty-reduction and sus- vative Jamaat Islami, which opposed a na- tainable development strategy that also ad- tional family planning program. Only during dressed gender inequality. Proposed strategies Benazir Bhutto’s second term in office during for achieving population stability by 2020 in- the mid-1990s, did family planning gain open cluded addressing the unmet need for con- political support. fertility Decline in pakistan, 1980–2006 | a case study 19 Institutional structure of the Provinces are responsible for program imple- Family Planning service Provision mentation, but employees in the provinces are system federal government employees. In contrast, During the Second Five-Year Plan, 1960−65, the provincial departments of health have a Family Planning Wing was established considerable autonomy. They set their own under the Ministry of Health, Labor, and So- priorities, plan programs, and use revenues cial Welfare, with a focus on clinic-based in- generated in the province. terventions. Under the Third Five-Year Plan, 1965−70, the population program was sepa- Collaboration between the Ministry of Popu- rated from the health program and transferred lation Welfare and Ministry of Health. These to the Ministry of Planning and Development differences in administrative structure and as the Population Welfare Division. During functioning make merger unlikely. One the Sixth Five-Year Plan, 1983−88, provincial study noted several incompatibilities: dif- population welfare departments were estab- ferent sources of funding and channels for lished, and field activities were transferred to fund flows and controls; different hierarchical the provinces. The Population Welfare Divi- and administrative relationships within each sion received ministry status during the Sev- sector, with population welfare only partially enth Five-Year Plan, 1988−93. Meanwhile, defederalized and health almost completely the Ministry of Health seemed to distance it- devolved; institutional inability to scale up self from responsibility for promoting family family planning service delivery at health out- planning through its facilities. A 1998 study lets despite several high-level directives over by the United Nations Population Fund rec- the years; and staff opposition as merger could ommended merging the ministries, and the threaten established career paths.75 government made plans to do so following in- The report also pointed out areas of co- ternal discussion in 2001.74 The two ministries operation between the ministries, particu- resisted merger, and, as a result, the parallel larly in service delivery, requisitioning and structures were maintained. distribution of contraceptives, and training to promote efficiency and noted other areas Administrative structure of the Ministry of Pop- for potential collaboration in service delivery: ulation Welfare and Ministry of Health. The the lady health workers, mobile services, and federal and provincial structures of both min- clinical family planning services at health fa- istries are similar. Responsibilities are divided cilities. Considering that family planning is between the federal government (ministries) not viewed as part of health services in rural and the four provincial governments (depart- and underserved areas and has been cultur- ments) headed by secretaries. Both ministries ally stigmatized, the potential for maximizing have district and tehsil (county) level admin- synergies appears to be greatest for integrating istrative units and service outlets. However, family planning services and basic health ser- the Ministry of Population Welfare’s program vices through existing Lady Health Worker planning and implementation are centralized, Program (see section on innovations in gov- and the ministry controls the flow of funds. ernment family planning services for more 20 detail on lady health workers). For sustain- each week, then returning to each village a able and meaningful collaboration to succeed, month later. however, will require removing impediments As part of the integration of family plan- that lady health workers face at the field level. ning services within basic health services now Workers are already overburdened in deliv- in progress, the Ministry of Health provides ering regular health services, leaving them family planning services through lady health little time to provide family planning services. workers, who provide oral contraceptives and Training in providing family planning services condoms and make referrals to health facili- is also required. And because the lady health ties for contraceptive surgery. The ministry workers report to officers of the Ministry of also provides services at some 12,500 health Health and provincial department of health, outlets, government hospitals, dispensaries, Ministry of Population Welfare officers have basic health units, rural health centers, and little influence over their performance. maternal and child health centers as part of comprehensive maternal, neonatal, and child the Government sector service health services.77 Service provision is often Delivery system for Family constrained by lack of staff knowledge, in- Planning adequate attention to family planning, and The Ministry of Population Welfare provides frequent stock-outs of contraceptive commod- services through an extensive network of insti- ities at health outlets. tutions in urban and rural areas. In 2008 the ministry had 2,740 Family Welfare Centers, Role of the Private sector and 176 Reproductive Health Service Centers–A, Nongovernmental organizations 117 Reproductive Health Service Centers–B, Private sector involvement in family planning and 292 Mobile Service Units. Family Wel- has historically been limited in Pakistan, ex- fare Centers provide family planning and cept for an ongoing social marketing program maternal and child health services. They dis- (see section on innovation in government tribute condoms, oral contraceptives, IUDs, family planning programs). Past family plan- and injectables. Each center serves about ning programs failed to involve the private 6,000 people.76 Reproductive Health Ser- sector in large-scale government programs.78 vice Centers are attached to service outlets in NGOs, in contrast, have a longer his- major hospitals. The “A” centers provide a full tory of family planning activities in Pakistan. range of contraceptives, contraceptive surgery, Though government support was sometimes and maternal and child health services. The lukewarm, NGO family planning activi- “B” centers include well established hospitals ties have not generally been restricted.79 The with fully equipped operating facilities such Ministry of Population Welfare has acknowl- as district/tehsil headquarter hospitals, NGO- edged the contributions of NGOs to pro- run clinics, and private hospitals. In remote moting population programs. The government areas, 292 Mobile Service Units each cover now provides grant financing to NGOs from some 30,000 people, providing two to three bilateral donor funding.80 There are several extension camps for family planning services well established NGOs in Pakistan delivering fertility Decline in pakistan, 1980–2006 | a case study 21 family planning services, such as the Family planning services, including community-based Planning Association of Pakistan; Pakistan workers and fixed outlets, while urban popula- Voluntary Health and Nutrition Association; tions have more options, including social mar- All Pakistan Women’s Association, an um- keting projects, which provide contraceptives brella organization with more than 40 NGOs; through a large network of outlets at subsi- and the Marie Stopes Society. dized prices. Following the International Conference Underutilization of government facilities on Population and Development in Cairo has been a concern across population groups in 1994, a nonprofit national umbrella or- and health services. People either do not go to ganization, the National Trust for Popula- these facilities or, having gone, are dissatisfied tion Welfare (NATPOW), was established to with the services and do not return. Only 12 strengthen NGO capacity in population wel- percent of households in rural and urban areas fare, reproductive health, maternal and child are satisfied with government family planning health, and community participation. Despite services, while 35 percent are satisfied with having more than 600 affiliated NGOs, it has basic health unit services.83 remained relatively ineffective. A 1998−99 evaluation of family welfare centers reported the following findings on status of the Family Planning quality of service and performance:84 services The public sector remains the main source Æ 343 new acceptors on average were reg- of contraceptives. In 2001−02, more than istered in the first half of 1997; of those, half of women who used modern contra- only a third was traceable (the survey ceptives obtained them from government found that numbers were often exagger- facilities and health workers, while 20 per- ated to meet targets). cent received them through the private sector Æ 30 percent of centers reported stock-outs and NGOs and 13 percent from other fa- of contraceptives of one month. cilities.81 The picture was roughly the same Æ 10 percent of centers had no family wel- in 2006−07, with 48 percent of modern fare workers. method users relying on the government Æ 59 percent of centers reported that an- sector, 30 percent on the private sector, and other center also provided family planning 12 percent on other facilities.82 The public services in the same village. sector is the main provider of female steril- Æ 30 percent of centers had no informa- ization (72 percent), while condoms are pro- tional material, and 30 percent of centers vided mainly through the private sector and with such material never distributed it. other sources. Oral contraceptives, inject- Æ 17 percent of clients received no infor- ables, and IUDs are provided almost equally mation on the benefits and side effects of by the public sectors and the private sectors/ contraceptives offered. other sources. Æ 48 percent of dropouts never received a Families in rural areas rely almost exclu- home visit by a family welfare worker to sively on public sector facilities for family encourage restarting contraceptive use. 22 Æ Half of family welfare workers reported for condoms and injectables, many of them no supervision visits in the past six supplied by the private sector.88 In 2000, the months. Multi-Donor Support Unit of the Social Ac- tion Program Project (see box 2 later in this According to 2001−02 survey data, less report) issued a note on pricing reproductive than half (46 percent) of health facilities (dis- health services, concluding that a small fee for pensaries, reproductive health services centers, all family planning services (a standard fee of and basic health units) had stocks of contra- Rs. 10.00 per couple per year was suggested), ceptives.85 with small incremental increases, would not Clients’ complain that distance barriers, affect demand. The report recommended re- especially in rural areas, prevent use of family ducing travel time to build demand and re- planning services. For example, 57 percent duce price elasticity, providing poor couples of survey respondents noted that the nearest with adequate contraceptives at public facili- maternal and child health center distributing ties, and ensuring that all Ministry of Health contraceptives was 10 or more kilometers outlets offer family planning services.89 from the village, and 41 percent reported that the nearest family welfare center was that far Government Financing of away.86 Population Programs Cultural constraints also limit women’s Government spending on population programs mobility in Pakistan. Because of the custom of has increased gradually since the late 1980s, women’s seclusion (purdah), women must be with some slippage in 1996/97 and 2000−02. accompanied by another family member when Spending rose from Rs. 415 million in 1990 they travel outside their village. One study to Rs. 8,965 million in 2005/06 (latest avail- found that only 20 percent of rural women able data), nearly double the 2004/05 amount. said that they would be able to visit a hospital Spending has been somewhat erratic, however, by themselves.87 Government actions to ad- unlike health sector spending, which has in- dress these barriers, through community-based creased steadily (figure 6). Nevertheless, popu- service provision or more village outlets could lation programs as a share of total government help to increase contraceptive prevalence in spending have increased sharply, though from rural areas. a low base, from 0.16 percent in 1990 to 0.45 Cost is another barrier to contraception percent in 2000 and 0.61 percent in 2005 use, especially for the poor. While the Min- (table 6). And despite the economic down- istry of Health does not charge for contra- turn, government spending on population and ceptive services, the Ministry of Population health increased under the Social Action Pro- Welfare does—Rs. 0.5 per condom and Rs. gram (SAP-I and II). These funding increases 3 for oral contraceptives (per cycle), IUDs, since the late 1980s likely contributed to the and injectables (per unit). The effect of price increase in contraceptive use and the decline in on contraception use is particularly evident the total fertility rate. fertility Decline in pakistan, 1980–2006 | a case study 23 Figure 6 | Government spending (FederalRupees) on Population and health, 1987–2006 (Millions of and Provincial) Population 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 1987–88 1988–89 1989–90 1990–91 1991–92 1992–93 1993–94 1994–95 1995–96 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02 2002–03 2003–04 2004–05 2005–06 Health 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 1987–88 1988–89 1989–90 1990–91 1991–92 1992–93 1993–94 1994–95 1995–96 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02 2002–03 2003–04 2004–05 2005–06 Federal Provincial source: calculated by the World bank based on the data from the accountant general of pakistan. table 6 | Government Expenditure on(percent) and health and Average Annual Growth, 1990/91–2005/06 Population share of total government expenditure (percent) Average annual growth (percent) 1987/88– 1990/91– 2000/01– 1990/91 2000/01 2005/06 1989/90 1999/00 2005/06 Population sector 0.16 0.45 0.61 27.9 26.5 42.1 health sector 2.06 2.36 2.90 7.1 12.9 19.4 source: calculated by the World bank based on the data from the accountant general of pakistan. 24 Pakistan’s Innovative Family Planning Programs Both the government and the private and analyze baseline data, so there is no way to NGO sectors have introduced new initiatives know whether the high contraceptive use rate in family planning programs over the years. can be attributed to the VBFPW. The evaluation also found some manage- Innovations in Government Family ment and implementation problems. For in- Planning Programs stance, nearly all women who participated in Under the Eighth Five-Year Plan (1993−98), the evaluation confirmed a visit by a family the government launched two community- planning worker in the past, but only about based programs in family planning: the Vil- half reported a visit in the month prior to the lage-Based Family Planning Worker scheme survey (the recommended schedule of visits (VBFPW) under the Ministry of Popula- is once a month). Moreover, while almost all tion Welfare in 1992/93 and the Lady Health workers were aware of their duty to provide Worker Program (LHWP) under the Ministry family planning information and methods to of Health in 1994/95. The idea was to bring users, only 60−70 percent understood that family planning programs directly to women they were also supposed to inform users of in rural areas, who were generally unable to contraceptive side effects and follow up with leave their homes or villages to travel alone to new acceptors. Another program evaluation family planning facilities. concluded that the scheme was a major con- The VBFPW scheme planned to cover tributing factor to the increase in contracep- 13,500 villages in all provinces by basing fe- tive use in the villages studied and found a male workers in their own village. This scheme strong relationship between the use of contra- borrowed many elements from the successful ceptives and the intensity of family planning Family Welfare Assistant scheme in Bangla- worker visits.91 desh. An evaluation in 2000 concluded that The LHWP, under the Ministry of the VBFPW scheme “has become the pivot Health, was developed to provide low-cost of activities of the Ministry of Population preventive services for communicable diseases Welfare in rural areas.”90 Contraceptive prev- and maternal and child health services, in- alence in program areas was 41.8 percent, sig- cluding family planning (lady health workers nificantly higher than the national average distribute oral contraceptives and condoms) reported in the Pakistan Demographic and to the entire population. The program’s re- Health Survey. The evaluation report did not cruitment criteria, training, remuneration, fertility Decline in pakistan, 1980–2006 | a case study 25 supervision, and method of service delivery approach holds great promise for increasing were almost identical to those adopted by the contraceptive coverage in rural areas. VBFPW program. By July 2005, there were about 88,000 lady health workers and su- Innovations in NGo and Private pervisors nationwide. One study found that sector Programs supported by women in rural areas served by lady health Donors workers were more likely to use a modern and Social marketing has been a bright spot in reversible contraceptive method than were Pakistan’s family planning activities. The women with no access to services.92 However, U.S. Agency for International Development the LHWP tends to serve more advantaged (USAID) launched support for a condom areas that are already slightly over-served and social marketing campaign in the mid- have a nearby functional health facility. To 1980s through the Social Marketing Paki- succeed, the program needs to reach out to stan (SMP) program with technical assistance the most underserved populations in rural from the NGO Population Services Interna- areas, where contraceptive use is still very low. tional. The project distributed some 354 mil- (See the detailed information on the program lion Sathi brand condoms until March 1994, evaluation in annex 1.) when USAID funding ended. Other donors Both programs have run into serious moved in to provide support, such as KfW management problems at the field level, in- (the German Development Bank), the U.K. cluding lack of effective coordination, duplica- Department for International Development tion of services, contraceptive stock-outs, and (DFID), and UN organizations such as the lack of local ownership.93 The 2000 program United Nations Population Fund (UNFPA) evaluation of the VBFPW program found (see box 1 for a summary of international that nearly half (47 percent) of the 43 percent donor support for population programs in of VBFPW respondents who reported that Pakistan and box 2 for World Bank support.) there was also a lady health worker in the vil- USAID resumed support after 2001. lage claimed that her presence hampered their KfW has supported social marketing since activities. In June 2002, following the rec- 1995 under the Greenstar model. Green- ommendations of a task force reviewing the star Social Marking Pakistan (GSMP) has ex- performance of population programs, a deci- panded its contraceptive options to include sion was made to merge the two programs; the oral contraceptive, IUDs, and injectables. LHWP is now also responsible for providing Product distribution is undertaken by SMP- family planning services at the household level certified service providers and outlets, in- in rural communities. cluding doctors, paramedics, and chemists. These government-sponsored commu- Coverage is mainly in urban and peri-urban nity health worker programs grew into one areas. Greenstar products are priced based on of the largest community approach schemes market research. in the world. Though improvements in ser- DFID supported social marketing of oral vice provision are still needed to achieve better contraceptives and injectables from 1996 to outcomes, this innovative community-based 2001 under the Key Social Marketing (KSM) 26 box 1 | Role of International Donors: external funding for population assistance to pakistan (programs and research for family planning, repro- ductive health, and HIV/aIDs) has fluctuated widely over the past decade. Donor funding specifically for family planning activities, has declined considerably over the 2000s, with average annual assistance falling almost in half, from $12.9 million during 1996–2000 to $6.7 million during 2001–05. The Ministry of population Welfare lists five key donors to population welfare programs in recent years: World bank (see box 2 for an overview of World bank assistance to the population sector), the asian Development bank, united nations population fund (unfpa), u.K. Department for International Develop- ment, and the german Development bank (KfW). The united Kingdom, germany, and the netherlands have provided consistent financial assistance since the 1990s, while the united states has a long, if intermittent, history of support, with a large increase in assistance since 2005. In recent years, usaID has increased its assistance to maternal and child health programs, including family planning, in pakistan. The five-year (2004−09) pakistan Initiative for Mothers and newborns (paIMan) provided a package of comprehensive maternity care in 11 districts and benefits more than 2.8 million married couples. The five-year (2007−12) family advancement for life and Health (falaH) project focuses on pregnancy spac- ing as a key health intervention to improve the survival and health of mothers and children. The project also trains providers and increases access to quality services in the public and private sectors. greenstar social Marketing pakistan is a partner of both projects, offering its expertise in private sector approaches. source: Hardee and leahy 2008; Ministry of population Welfare (http://www.mopw.gov.pk/); organisation for economic co-operation and Development (oecD) Development assistance committee (Dac) database (http://stats.oecd.org/ Index.aspx?Datasetcode=oDa_RecIp). note: figures reported in the oecD/Dac database, especially for multilateral donors, are often underreported. program. KSM contracted with a manufac- contraceptive products. Their promotional turer to produce, package, and distribute its campaigns complemented government efforts Key products to enlisted retailers. Price was but used original and focused messages on TV, based on market research. radio, cinema, newspapers, and other infor- The social marketing projects seek to ex- mation media. The campaigns increased the pand coverage of family planning services in visibility of family planning products and pro- urban areas, develop a cadre of skilled per- vided information on proper use, prices, and sonnel, satisfy the unmet need for contra- sources of supply. ceptives, and accustom people to paying for Today, GSMP and KSM together provide services. The two projects have established a a third (30 percent by GSMP and 3 percent by network of more than 56,000 outlets and ser- KSM) of all modern contraceptives in Pakistan, vice facilities in urban and peri-urban areas, a while the public sector delivers 59 percent, ac- great leap forward in the accessibility of family cording to GSMP.94 The share is higher for con- planning services. GSMP reported that more doms, with 78 percent of urban condom users than 16,000 private health care providers reporting using a social marketing brand.95 were registered with the Greenstar health care Though the impact of social marketing providers network as of 2005−06. These so- on fertility reduction in urban areas has not cial marketing projects adopted creative ap- been rigorously studied, it appears that social proaches to building sustained demand for marketing projects might have contributed fertility Decline in pakistan, 1980–2006 | a case study 27 box 2 | world bank Assistance to the Population sector in Pakistan The World bank has supported population issues in pakistan through policy dialogue with the government (poverty Reduction strategy papers and the country assistance strategy) and through direct assistance on the following projects since 1983: • population project (1983–89, us$18.0 M). • social action program project I (1993−97, us$200 million). • social action program project II (1998−03, us$250 million). • family Health project I (1992−99, us$45.1 million). • family Health project II (1994−99, us$48.0 million). • population Welfare program project (1996−2000, us$65.1 million). • northern Health project (1996−2000, us$26.7 million). In 1992, pakistan launched the social action program (sap), a broad-based social sector reform program to improve the access to and quality of basic social services in four sectors including population welfare. several donors, including the World bank, the asian Development bank, the u.K. Department for Interna- tional Development, and the government of the netherlands, supported the sap through the social action program project (sapp-I, 1993−97). a follow-on sapp-II (1998−2003) built on the lessons of the first project. Taking a sector-wide approach to key underlying institutional issue, the projects aimed to increase govern- ment spending on basic social services; build government capacity for planning, monitoring, and implement- ing social service programs; and encourage ngo and private sector participations. The two projects appear to have protected social sector and sap budget allocations during 1993−97 from the drastic cuts made in other public programs. The projects also created a supportive institutional policy framework for the health sector and provided a common tool for policy dialogue between the govern- ment and donors. policy issues addressed through the projects included providing family planning services through health outlets, improving coordination between population and health facilities, training health staff in family planning, and supplying contraceptives to health outlets. sapp-I and II helped create an enabling environment for other population-related projects implemented in the 1990s: family Health I (nWfp and sindh) and II (balochistan, punjab Islamabad capital Territory), population Welfare, and northern Health. These projects aimed to increase contraceptive use by integrat- ing family planning into primary health services, increasing demand for contraceptives through information activities, training health personnel, increasing contraceptive supplies at health outlets, and supporting the private sector. contraceptive prevalence nearly doubled in all provinces over the course of the projects. no systematic impact evaluations were conducted to isolate the impact of bank-assisted population projects, it is thus not possible to attribute increased contraceptive use or declining fertility directly to the projects. However, the period of intensive bank support coincided with the period of rapid increase in con- traceptive prevalence and decline in the total fertility rate after decades of sustained high fertility. source: World bank 1990, 1998, 2003, 2000a, 2000b, 2000c, 2001. to higher contraceptive prevalence rates and in the second half of 1990s, (2) there was a fertility reduction. The analysis on fertility steady rise in CPR since the early 1990s and and contraceptive changes in urban Pakistan reached around 40% percent by 2000, (3) the during the 1990s to explore the role played most reported method by urban couples was by social marketing initiative provides the fol- condom, and (4) there was a significant rise lowing results: (1) the decline in urban fer- in the use of oral pills and injectables during tility level was less erratic and a bit faster 1996–2001.96 28 table 7 | 1990sin total Fertility Rate and contraceptive Prevalence Rate During trend total fertility rate contraceptive prevalence rate Year urban Rural urban Rural 1990/91 4.9 5.6 25.7 5.8 1994/95 — — 32.0 11.0 1996/97 4.3 5.9 36.5 18.6 2000/01 3.7 5.4 39.6 21.7 source: ahmed 2002. The challenges ahead include addressing grams, and promoting local manufacturing.97 unmet need in urban areas, supporting re- In addition, using social marketing schemes productive health approaches, linking social to increase coverage in rural areas should be marketing programs with other private sector considered to help fill the gap in contraceptive programs and public sector population pro- availability. fertility Decline in pakistan, 1980–2006 | a case study 29 Implications P akistan’s complex history of popula- able impact on fertility rates. However, the tion programs is a lesson for its planners programs have several shortcomings, and Paki- as well as other high-fertility countries. stan has made little progress in reducing socio- During the 1990s, as family planning services cultural constraints to family planning (related improved, contraceptive prevalence rates more to religion, gender, and rural-urban division). than doubled and the total fertility rate fell an The government needs to address program estimated 40 percent. Two innovative commu- shortcomings immediately to meet high level nity-based programs begun in the 1990s and of unmet needs for contraceptives. In parallel, the involvement of the private sector in family underlying socio-cultural constraints should planning through the Greenstar Network so- be improved to accelerate fertility reduction in cial marketing initiative likely had consider- the long run. 30 Annex 1. Evaluation of the Lady health worker Program I n 2002, Oxford Policy Management con- characteristics of Lady health ducted an evaluation of the Lady Health workers Worker Program (LHWP) covering 1999– Lady health workers are contract employees. 2002, assessing the effectiveness and impact They must be married, age 20–50, have at of the program, especially among underserved least eight years of schooling, and live and groups.98 work in the communities they serve. They re- ceive both full-time and in-service training. Implementation Issues The supervision system appeared to be func- The program has been implemented under the tioning well: 70 percent of lady health workers Ministry of Health since 1994/95. Though reported that they had had a supervision planned at Rs.9.1 billion over five years, ac- meeting in the month before the survey. Lady tual levels of funding have been considerably health workers are supported by nearby first- lower. The amount spent on drugs and con- level care facilities. traceptives per lady health worker was 84 per- On average, lady health workers make 25 cent lower than planned, salaries have fallen household visits and see 20 clients a week. The 20 percent in real terms, and real unit cost workload is lowest in Sindh and Balochistan. per lady health worker fell 51 percent from Around 40–50 percent of eligible families 1994/95 to 2000/01. have received services (not limited to family This severe underspending likely under- planning). Service levels are highest in Azad mined the effectiveness and impact of the Jammu and Kashmir and Northern Areas and program. Undersupply of contraceptives was lowest in Balochistan. Lady health workers especially critical; 38 percent of lady health provide 40 percent of total contraceptives in workers were without condoms and 67 per- Balochistan, as they are assumed to be the cent were without oral contraceptives at the main source of contraceptive supply. Though time of the survey. Only 32 percent of workers the level of knowledge of lady health workers had been paid in the month prior to the was fairly good, only 20 percent of them pro- survey, and 34 percent had not been paid for vided eligible couples with information related more than three months. And 20 percent of to family planning. High performing workers workers received salaries below what they were had higher levels of knowledge and were more entitled to. likely to receive supervision and supplies. The fertility Decline in pakistan, 1980–2006 | a case study 31 Pakistan Demographic and Health Survey dicators. Nonetheless, lady health workers ap- of 2006–07 found that lady health workers pear to have affected the provision of family reached only 23 percent of nonusers of contra- planning. Use of any contraceptive method ceptives to discuss family planning issues. Of was 30 percent in program areas compared those contacted, only 9 percent had received with 21 percent in control areas and 22 per- information on family planning, 3 percent cent for the national average, and use of any had received family planning supplies, and 2 modern method was 20 percent in program percent had received a referral to a health fa- areas, 14 percent in control areas, and 15 per- cility in the previous 12 months. cent for the national average. outcomes and Impacts of the Limitation of the Evaluation Program The evaluation compared program and con- Overall, areas served by lady health workers trol areas at the time of the survey, because it have better health indicators than control pop- did not collect baseline data on health status ulations and the national average. However, in program and control population groups at lack of baseline data precluded establishing the beginning of the intervention. In addition, whether the differences were due to the pro- the evaluation did not assess program impact gram or to other differences between program on the fertility rate or the infant mortality rate and control areas, such as socioeconomic in- because the rate of change was too slow. 32 Annex 2. country-at-a-Glance: Pakistan Earliest available data Latest available data Indicator Value Year Value Year Economy gnI per capita (World bank atlas method, cur- 330 1980 800 2006 rent us$) gnI per capita (purchasing power parity, current 620 1980 2,410 2006 international $) poverty gap at national poverty line (percent) 7 1999 7 1999 Demography population, total 82,730,331 1980 159,002,039 2006 population growth (annual percent) 2.9 1980 2.1 2006 population ages 0–14 (percent of total) 42.7 1980 36.4 2006 urban population (percent of total) 28.1 1980 35.3 2006 fertility rate, total (births per woman) 7.0 1980 3.92 2006 adolescent fertility rate (births per 1,000 women 68.84 1997 32.89 2006 ages 15–19) life expectancy at birth, female (years) 55.7 1980 65.8 2006 Mortality rate, infant (per 1,000 live births) 110 1980 77.8 2006 Mortality rate, under-five (per 1,000 live births) 153 1980 97.2 2006 Maternal mortality ratio (modeled estimate, per 320 2005 320 2005 100,000 live births) health Health expenditure, total (percent of gDp) 2.3 2001 2.1 2005 Health expenditure, public (percent of gDp) 0.5 2001 0.4 2005 Health expenditure per capita (current us$) 10 2001 15 2005 Immunization, measles (percent of children ages 1 1980 80 2006 12–23 months) Malnutrition prevalence (weight for age, percent 39.0 1991 31.0 2001 of children under five) births attended by skilled health staff (percent of 18.8 1991 31 2005 total) contraceptive prevalence (percent of women 11 1984 27.6 2001 ages 15–49) (continued on next page) fertility Decline in pakistan, 1980–2006 | a case study 33 (continued) Earliest available data Latest available data Indicator Value Year Value Year nurses and midwives (per 1,000 people) 0.45 2005 0.45 2005 physicians (per 1,000 people) 0.29 1980 0.80 2005 Education literacy rate, adult female (percent of women 26 1996 35.4 2005 ages 15 and older) school enrollment, secondary, female (percent 22.9 2003 25.8 2006 net) school enrollment, primary, female (percent net) 46.0 2001 57.3 2006 primary completion rate, female (percent of 51.0 2005 52.9 2006 relevant age group) source: World bank, World Development Indicators online, retrieved January 9, 2009. 34 References Agha, S. 2000. “Is Low Income a Constraint with Practice of Modern Contracep- to Contraceptive Use Among the Paki- tive Methods among Currently Married stani Poor?” Journal of Biosocial Science Women in District Naushahro Feroze.” 32(2): 162–275. 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Washington, D.C. ———. 2001. “Implementation Completion ———. 2007. World Development Indicators Report for the Northern Health Program 2007. Washington, D.C. Project.” Report No. 22263. Washington, Zafar, MI., F. Asif, and S. Adil. 2003. “Reli- D.C. giosity as a Factor of Fertility and Con- ———. 2002. “Pakistan Country Assistance traceptive Behavior in Pakistan.” Pakistan Strategy.” Washington, D.C. Journal of Applied Sciences 3(3): 158– ———. 2003. “Implementation Completion 166. Report for Second Social Action Program fertility Decline in pakistan, 1980–2006 | a case study 39 Endnotes 1 Population projection based on 1998 11 Sathar and Casterline 1998; Sathar 2007. Census prepared by National Institute of 12 Sathar 2007. Population Studies (2005). 13 A measure comparing the age-specific pro- 2 Feeney and Alam 2003a. portions of women who have never been 3 Sathar and Casterline 1998. married with the age-specific proportions of 4 Feeney and Alam (2003b) question those who have ever been married to calcu- whether the total fertility rate really fell late the mean age at which the transition be- that rapidly or whether the rate of decline tween the two occurs. It is used to estimate was exaggerated by the deterioration in the mean age at marriage in countries where quality of birth reporting. However, agree- marriage records are absent or deficient. ment among several independent estimates 14 Pakistan Demographic and Health Survey suggests that the estimates are all at least data (National Institute of Population approximately correct. Studies and Macro International Inc. 5 The total fertility rate calculated from the 1992, 2008). Pakistan Demographic Survey, a large 15 Pakistan Demographic and Health Survey sample survey conducted by the Federal data (National Institute of Population Bureau of Statistics, is based on births re- Studies and Macro International Inc. ported during the past year. The total fer- 1992, 2008). tility rate calculated from the surveys 16 National Family Health Survey-III conducted by the Ministry of Population 2005−06 for India, Demographic and Welfare and the National Institute of Pop- Health Survey 2006 for Nepal, Demo- ulation Studies is based on three- to five- graphic and Health Survey 2004 for Ban- year recall of births, which are likely to be gladesh, and Demographic and Health underreported by uneducated women. Survey 2006−07 for Sri Lanka. 6 Feeney and Alam 2003a. Sathar and Cast- 17 Sathar and Casterline 1998. erline (1998) also argue that 1990–91 18 Pakistan Demographic and Health Survey Pakistan Demographic and Health Survey 2006–07 (National Institute of Population fertility rate was seriously underestimated. Studies and Macro International Inc. 2008). 7 Feeney and Alam 2003b. 19 Pakistan Demographic and Health Surveys 8 Sathar 2007. (National Institute of Population Studies 9 These were suggested Bongaart (1978). and Macro International Inc. 1992, 2008). 10 Aziz 1994 and Ahmed, Mohamed, and 20 Pakistan Demographic and Health Survey Khan 1994. data (National Institute of Population 40 Studies and Macro International Inc. tionnaires were adopted from instruments 1992, 2008). developed by the Guttmacher Institute. 21 According to the 2006−07 Pakistan Demo- 29 Saleem and Fikree 2005. graphic and Health Survey, about 60 per- 30 Sathar, Singh, and Fikree 2007. cent of female sterilization clients reported 31 Guttmacher Institute 2009. that it was free of cost, compared with 30 32 Rehan 2003. percent of oral contraceptive users, 15 per- 33 Pakistan Demographic and Health Survey cent of intrauterine device users, 14 per- 2006−07 (National Institute of Popula- cent of condom users, and 13 percent of tion Studies and Macro International Inc. injectable contraceptive users (National In- 2008). stitute of Population Studies and Macro 34 Pakistan Demographic and Health Survey International Inc. 1992, 2008). 1990−91 and 2006–07 (National Institute 22 Pakistan Demographic and Health Survey of Population Studies and Macro Interna- 2006−07 (National Institute of Population tional Inc. 1992, 2008). Studies and Macro International Inc. 2008). 35 lram and Butt 2008, using data from 23 Pakistan Demographic and Health Survey Pakistan Integrated Household Survey 2006−07 (National Institute of Popula- 2001−02. tion Studies and Macro International Inc. 36 (National Institute of Population Studies 2008). and Macro International Inc. 1992, 2008) 24 For Nepal, Demographic and Health Survey 1990−91 and 2006–07. Survey 2006; for Cambodia, Demographic 37 Pakistan Demographic and Health Survey and Health Survey 2005. 1990−91 and 2006–07 (National Institute 25 India National Family Health Survey III of Population Studies and Macro Interna- 2005−06. tional Inc. 1992, 2008). 26 Pakistan Demographic and Health Survey 38 Pakistan Demographic and Health Survey 2006−07 (National Institute of Popula- 2006–07 (National Institute of Popula- tion Studies and Macro International Inc. tion Studies and Macro International Inc. 2008). 2008). 27 Pakistan Demographic and Health Survey 39 Winkvist and Akhtar 2000. 2006−07 (National Institute of Popula- 40 Hussain, Fikree, and Berendes 2000. tion Studies and Macro International Inc. 41 Kadir and others 2003. 2008). 42 Hussain, Fikree, and Berendes 2000. 28 Sathar, Singh, and Fikree 2007. This study 43 Soomro and Mahmood 2005. used data from a health facilities survey 44 Pakistan Gender Assessment 2005, based covering 17 percent of public health fa- on Pakistan Integrated Household Survey cilities and 65 percent of hospital beds in 2001−02. public facilities, and a health professionals 45 Pakistan Demographic and Health Survey survey conducted in 2002, which used 1990−91 and 2006–07 (National Institute structured interviews of 154 health pro- of Population Studies and Macro Interna- fessionals across the country. Both ques- tional Inc. 1992, 2008). fertility Decline in pakistan, 1980–2006 | a case study 41 46 King and Hill 1998. 69 The increase in the price of condoms in 47 The Pakistan Gender Assessment 2005. 1991 might have contributed to the in- 48 Sathar and others 2000. creased use of withdrawal after 1991 (Agha 49 Hausmann, R., L.D. Tyson, and S. Zahidi 2000). 2008. 70 Population Briefs 1998. 50 Labor Force Survey 2006−07 (Pakistan 71 Ahmed n.d. Federal Bureau of Statistics 2008). 72 Karim and others 2004. 51 Conventionally, people ages 10 and older 73 Ahmed n.d; Hakim 2001; Lush and others reporting housekeeping and related activi- 2000; Lee and others 1998. ties are considered out of the labor force. 74 UNFPA 1998. However, from the perspective of time use, 75 Nishtar and others 2008. they are identified as employed if they have 76 Ministry of Population and Welfare 2008. spent time on a specific set of marginal 77 According to the Ministry of Health web- economic activities (Labor Force Survey site, there are 13,937 health facilities. Of 2006−07, table 6, Pakistan Federal Bureau those, 371 Tuberculosis Centers and 1,080 of Statistics 2008). First Aid Points do not offer contraceptives. 52 Pakistan Demographic and Health Survey 78 Robinson 2007. 2006−07 (National Institute of Population 79 Karim and others 2004. Studies and Macro International Inc. 2008). 80 Karim and others 2004. 53 Mahmood 2002. 81 Pakistan Integrated Household Survey 54 World Bank 2005. 2001−02 (Pakistan Federal Bureau of Sta- 55 Sathar and Kazi 2000. tistics 2003). 56 Jejeebhoy and Sathar 2001. 82 Pakistan Demographic and Health Survey 57 Karim 2005. 2006−07 (National Institute of Popula- 58 Zafar and others 2003. tion Studies and Macro International Inc. 59 Ali and Ushijima 2005. 2008); disaggregated data on the source of 60 Ali, Rozi, and Mahmood 2004; Ste- modern contraceptives by residence (rural phenson and Hennink 2004; Ali and and urban areas) are not available. White 2005. 83 Pakistan 2006–07 Social and Living Stan- 61 Ali, Rozi, and Mahmood 2004. dards Measurement Survey (Pakistan Fed- 62 Stephenson and Hennink 2004. eral Bureau of Statistics 2008). 63 Kiani 2003; Saleem and Isa 2004. 84 The evaluation study was conducted 64 Casterline, Sathar, and ul Haque 2001. during 1998–99 by the National Institute 65 Mahmood 2002. of Pakistan Studies with a random sample 66 Ali, Rizwan, and Ushijima 2004. of 73 family welfare centers (5 percent of 67 Casterline, Sathar, and ul Haque 2001. the total) and 80 clients from each family 68 Pakistan Demographic and Health Survey welfare center contacted. 2006–07 (National Institute of Popula- 85 Pakistan Integrated Household Survey tion Studies and Macro International Inc. 2001−02 (Pakistan Federal Bureau of Sta- 2008). tistics 2003). 42 86 Pakistan Demographic and Health Survey vember 1994) of 10 percent of households 2006−07 (National Institute of Popula- in 21 villages (about 400 interviewees per tion Studies and Macro International Inc. survey) and a series of observation studies in 2008). Punjab for 550 observations of interactions 87 Sultan, Cleland, and Ali 2002. with clients and 76 workers were collected. 88 Agha 2000. 92 A logistic regression analysis by Douth- 89 Ahmed 2000a. waite and Ward (2005) using data collected 90 The evaluation (Popalzai and Sikander for the program evaluation conducted in 2000) covered the performance of village- 1999–2002 by Oxford Policy Management based family planning workers, verifica- (sample survey of 4,277 women living in tion of clients and their views, and the households served by the LHWP or in role of trainers and supervisors. System- control areas). atic random sampling was used to select 93 Islam, Malik, and Basarja 2002. 373 family planning workers out of 7,446. 94 Greenstar Social Marketing website at As a second stage, 15 eligible women per http://www.greenstar.org.pk/FPRH.htm worker were selected for interviews, along 95 Pakistan Demographic and Health Survey with 145 trainers and supervisors. 2006−07 (National Institute of Population 91 Lush and others 1998 and Sultan; Cle- Studies and Macro International Inc. 2008). land, and Ali 2002. The evaluation by Lush 96 Ahmed 2002. and others involved three community sur- 97 Ahmed 2002. veys (August and December 1993 and No- 98 Oxford Policy Management 2002. fertility Decline in pakistan, 1980–2006 | a case study THE WORLD BANK 1818 H Street, N.W. Washington, DC 20433