volume 4, issue 1
October 6, 2008
PAI Research Commentary By Karen Hardee and Elizabeth Leahy
Since 2001, the geopolitical significance of Pakistan has become increasingly clear to the world, as has the countrys instability. Throughout this decade, Pakistan has suffered from growing strife, including, in the last year, the assassination of former Prime Minister Benazir Bhutto and the bombing and destruction of the countrys most prominent American-owned hotel. The recent change in government from military to fragile civilian rule, accompanied by growing strength among extremists in tribal areas, has only compounded the precarious nature of the country's security.1
from these recent headlines, few outsiders may realize the significant role that demographics play in Pakistans overall development and security. And few are likely aware of the stagnation of Pakistans family planning program, which provides key services to Pakistani families and affects the countrys larger demographic trajectory. The provision of comprehensive, voluntary family planning and reproductive health services is a fundamental human right, and yet today these services still remain out of reach for millions of Pakistanis.2 In fact, one-quarter of married women want to either wait before having another child or end childbearing altogether, but are not using a method of contraception. The broader impacts of this unmet need for family planning on health and development are significant and should not be ignored.
In countries such as Pakistan, the challenges of providing for peoples well-beingopportunities for education and employment, as well as access to quality health carecan be exacerbated by a rapidly growing population. Research has found that countries with a very young and youthful age structurethose in which at least 60 percent of the population is younger than 30, like Pakistan (Figure 1)are more likely to have autocratic governance and face outbreaks of civil conflict.3 Young people are not inherently problematic or dangerous, and many countries with very young age structures achieve higher levels of development without internal conflict. However, governments that are already weak, unstable or corrupt can see their political and economic resources further strained by demographic factors.
Figure 1. Pakistans Age Structure, 2005
The context for providing family planning in Pakistan is challenging. The political strife that has intensified over the past two decades, coupled with cultural constraints limiting the empowerment of women, make the implementation of effective programs in many parts of the country difficult. As a result, most Pakistani women who say they have had enough children or that they want to wait to have their next child do not have ready access to the contraceptive services and reproductive health care they need. Pakistans family planning program needs strong and consistent leadership, a sustained strategy to expand access to services and adequate resources.
Pakistan was among the vanguard countries in Asia in starting a family planning program more than five decades ago, with intermittent support from international donors including the United States. Despite this history, fertility has declined more slowly in Pakistan than in most other Asian countries (Figure 2). Related measures of maternal and child health are concerning as well; the countrys infant mortality rate of 75 deaths per 1,000 live births is higher than in Bangladesh, India, Nepal and Sri Lanka. In 1950, Pakistan had a population of 37 million people and was the worlds 13th largest country as measured by population. By 2007, Pakistan was the sixth largest country with 164 million people. Pakistan is projected by the United Nations to move to fifth place in 2050 with 292 million people, after India, China, the United States, and Indonesia.4
Figure 2. Total Fertility Rates in Selected South Asian Countries, 1965-20055
Fertility Remains High at Four Children
Results from the 2006-07 Demographic and Health Survey (DHS)6 show that Pakistans fertility rate has remained persistently high over the past decade (Figure 3)7. The total fertility rate (TFR)8 in Pakistan is now 4.1 children per woman. Women in urban areas have an average of 3.3 children compared to their rural counterparts, who have an average of 4.5 children.
Currently married women in Pakistan report that on average, their ideal family size is 4.1 children, which is equal to their actual total fertility rate. However, women also say that 24 percent of recent births were mistimed or unwanted; rural and poor women are especially likely to have more children than they want to have. Although family planning decisions tend to be made by couples rather than by women alone, communication is sometimes lacking; about one-fifth of women dont know how many children their husband would like to have.9
Figure 3. Estimates of Pakistans Fertility Rate, 1994-200610
Pakistan remains a predominantly rural country with an unevenly distributed population. One-third of the women interviewed in the 2006-07 DHS lived in cities, while two-thirds lived in rural areas. Nearly 80 percent of the population lives in the two eastern provinces, Punjab and Sindh (Figure 4)11. The DHS reflects this geographic distribution; of the 10,023 women of reproductive age interviewed in the DHS:
58 percent were from the Punjab,
24 percent were from Sindh,
14 percent were from the North West Frontier Province (NWFP), and
5 percent were from Balochistan12.
Figure 4. Map of Pakistan
Available from
Home-Planning Commission of Pakistan
Women Know About Family Planning, but Knowledge Does Not Always Translate into Use
After nearly 50 years of family planning programs in the country, 96 percent of currently married women are aware of at least one modern method of contraception. However, only half of Pakistani women said they had ever used contraception and, at the time of the 2006-07 survey, only 22 percent of married women who were not currently pregnant said they were currently using a modern contraceptive method; another eight percent were using less effective traditional methods.
Although Pakistan had success in increasing contraceptive use in the 1980s and 1990s, a plateau has been reached in recent years. The contraceptive prevalence rate (CPR), or the percentage of married, non-pregnant women using both modern and traditional methods of contraception, rose from 12 percent in 1990-91 to 28 percent in 2000-01, but has remained around 30 percent since then. Almost half of currently married women have used contraceptives (modern or traditional methods) at one time, indicating that a significant share of women have discontinued use of family planning.
The most common contraceptive methods in use in Pakistan are either long-term or have low effectiveness (Figure 5). These include female sterilization (8 percent of married women), traditional methods such as rhythm and withdrawal (8 percent), and condoms (7 percent). Contraceptive use is lowest among young and rural women, but rises with education. Women living in urban areas are two-thirds as likely to use modern contraceptives as those in rural areas (30 and 18 percent prevalence rates, respectively). The gap between women with differing levels of education is smaller than the rural-urban divide, but still significant. Only 19 percent of women with no education are using a modern method of family planning, compared to 26 percent of women who completed secondary school. The link between higher levels of education among women and smaller family size across the developing world is clear; on average, each year of girls education has been found to reduce fertility rates by 0.3 to 0.5 children per woman.13 This is a particularly salient connection for Pakistan, where most womenfully 65 percent of those surveyed in the DHShave no education.
Figure 5. Current Use of Contraceptive Methods among Married Women Age 15-4914
A large share of Pakistani women continue to have an unmet need for family planning; that is, they want to either wait for their next child or not have any more children but are not using a method of contraception. One-quarter of married women of reproductive age are estimated to have an unmet need, with a greater share of the need among women who say they want no more children. Unmet need is highest among the poor, those living in rural areas, and women with no education.
Among married women who are not using family planning and have no intention to use contraceptives in the future, only three percent cite a desire for more children as their reason, and another three percent dont know how to use or obtain a contraceptive method. The most common barriers to use of family planning among married women are a belief that fertility should be determined by God (28 percent); opposition to use by the woman, her husband, others or a perceived religious prohibition (23 percent); infertility (15 percent); and concerns about health, side effects or the cost of family planning (12 percent).
More Women in Pakistan Would Use Contraception if Services Were More Widely Available
Many experts have written about Pakistans family planning program and the reasons for its limited success.15 Causes relate to both the strength and reach of the family planning program and to strong cultural deterrents to contraceptive use, such as religious beliefs and womens limited autonomy in decision-making. Over the years Pakistans family planning program has experienced varying levels of political and donor support and many shifts in strategy and program management.
In the early 1990s, when contraceptive prevalence was 14 percent, a mere 20 percent of the countrys population was considered to be effectively covered by Pakistans Population Welfare Program.16 At that time, one study found that women living in villages covered by a family planning center were much more likely to be using contraception than those outside the village.17 Given womens limited mobility due to the cultural practice of Purdah, in which womens activities outside the household are severely constrained, many women were likely out of reach of reproductive health care even when clinics were available in their villages. Zeba Sathar, the director of the Population Council in Pakistan has noted that the subordinate status of womenwhose legal rights may have even weakened in recent decadesas well as the governments past neglect of the education sector have direct implications for fertility rates.18 Women remain underrepresented in many aspects of Pakistani society. Only 35 percent of adult women are literate, compared to 65 percent of men; and women represent just one-quarter of the countrys professional and technical workers. 19
To help address cultural and geographic barriers, in the early 1990s Pakistan instituted outreach programs in which women are visited at home in their villages by Lady Health Workers, members of the community who have received 15 months of training to deliver primary health care.20 A recent evaluation of the Lady Health Workers program found that womens movement was still constrained. The 2002 evaluation found that only 15 percent of rural women had been outside their village in the previous month without being accompanied by another adult,21 and confirmed that services are much more effective when offered closer to where women live. Contraceptive use in villages with the community-based workers was 74 percent higher than in villages without.22
Pakistans family planning program is administered by two government ministries, the Ministry of Health (MOH) and the Ministry of Population Welfare (MOPW), which have each had inefficiencies in implementation. In both ministries, delivery of family planning services has been plagued by weak logistics systems and lack of contraceptive methods at service points as well as staff ill-trained and ill-equipped to provide quality services to clients. The Lady Health Workers program, while successful in reaching more women, faces high turnover of staff.
Pakistans Population Policy
Pakistans latest population policy dates from 2002, and reflects the governments concerns about the rapid pace of population growth and its link to persistently high rates of poverty in the country.23The objectives of the policy are to reduce population growth (from 2.1 percent in 2002 to 1.9 percent by 2004 and 1.3 percent by 2020) and to reduce fertility through voluntary family planning (to 4 births per woman by 2004 and 2.1 births per woman by 2020). Pakistan has pledged to provide universal access to family planning by 2010, in line with being a signatory along with the United Statesto the Programme of Action of the 1994 International Conference on Population and Development in Cairo.
Given the persistently high fertility rates and unmet need for family planning outlined in the recent Demographic and Health Survey findings outlined above, major challenges remain in achieving the objectives of the population policy. According to the governments Poverty Reduction Strategy Paper, the population policy also outlined a goal to steadily increase contraceptive use, with prevalence rising to 43 percent in 2006 and 57 percent in 2012.24With the target for 2006 already missed, access to family planning will have to scale up rapidly to reach 57 percent in the next four years.
Beyond the stagnation of the family planning programs reach, Pakistan faces broad challenges to improving womens reproductive health. As assessed by PAIs A Measure of Survival, the country falls in the high risk category for womens sexual and reproductive health. Only 16 percent of women receive at least four antenatal care visits during pregnancy, fewer than one-third of births are attended by skilled health personnel, and the maternal mortality ratio, at 320 maternal deaths per 100,000 live births, remains high.25,26
Trends in Funding for Family Planning in Pakistan
External funding for population assistance (comprising programs and research related to family planning, reproductive health, HIV/AIDS) in Pakistan has fluctuated significantly over the past decade. The total donor funding level of $32.5 million in 2005 was a slight decline from the $33.5 million received in 1996, although it varied dramatically in the intervening years, from as high as $57.3 million in 2003 to as low as $9.5 million in 2004.27
Figure 6. Donor Support for Population Assistance to Pakistan, 1996-200528
Within overall population assistance, funding for family planning activities in Pakistan has declined considerably in the 2000s, with average annual support falling by nearly half from $12.9 million from 1996-2000 to $6.7 million between 2001-2005. Donor support for reproductive health, which includes activities such information and education and prenatal, post-natal and safe delivery care, peaked in 2004 at $35.1 million, mainly due to a very large contribution from the government of the United Kingdom. The median annual external funding for reproductive health has been $9.1 million over the ten-year period. Meanwhile, funding for HIV/AIDS has generally been below that of both family planning and reproductive health, averaging $3.5 million annually. HIV/AIDS has not spread widely across Pakistans population, with prevalence among adults estimated at 0.1 percent in 2007.29
Bilateral and multilateral organizations, such as the United Nations and World Bank, have historically provided the bulk of donor support for population activities in Pakistan. U.S. government population assistance to Pakistan has been sporadic for most of the past decade. Until 2005, the U.S. Agency for International Development (USAID)s highest level of annual population funding had been just over $600,000. However, in 2005 USAID provided $10.6 million to Pakistan, with nearly 80 percent of the funds directed to family planning activities. For example, USAIDs Family Advancement for Life and Health project, implemented by the Population Council, works to raise awareness about the health benefits of birth spacing and train family planning providers.
The Future for Family Planning in Pakistan
Expert demographer and family planning program specialist John Ross and colleagues have found that countries in which contraceptive prevalence reaches a plateau generally take steps to address the stall in family planning use, and that plateaus rarely repeat in a county. Their analysis has also found that once prevalence reaches the range of about 25 percent it continues upward.30Although total contraceptive prevalence (including both modern and traditional methods) is 30 percent in Pakistan, this is an increase of only 0.3 percent annually since 2000-01 and a decline from a measurement of 32 percent in 2003, which seems to signal a plateau. Likely factors for the current plateau in family planning include weakened programs at all levels and a narrow method mix, with few effective options of short term methods.
Still, some factors bode well for the future of Pakistans family planning program. There is a clear latent demand for family planning, with 70 percent of married women using no contraceptive method and 25 percent indicating an unmet need for family planning. Long-term methods, which by nature have lower discontinuation rates, are popular. Further, Pakistans low HIV prevalence means fewer stresses on reproductive health budgets and less competition for funding.
Past initiatives have shown that most women want to determine their own family size and that they use family planning when they have access to services and have had educational opportunities themselves. Pakistans challenge is to expand access to high quality, voluntary family planning and reproductive health care so that individuals and couples can meet their desires for smaller families, while also improving womens standing within families and society. That means expanding access to family planning in rural and hard-to-reach urban areas, as well as among the poor, and focusing on eliminating gender disparities.
Although young age structures can exacerbate challenges to development, these profiles are not static. Pakistans government should also take heed of the proven and cost-effective family planning and reproductive health policies that can promote greater demographic balance. Meanwhile, donors such as the United States, which have already identified Pakistan as a key strategic ally worthy of intense political cooperation, should ensure that the health and well-being of Pakistans people are no less of a priority. Working together, Pakistans government and donors can help Pakistani women and men achieve their desired family size by providing consistent support for Pakistans efforts to provide voluntary family planning.
