Family planning trends and programming in Pakistan.

OBJECTIVE

Pakistan's struggle to revitalize its family planning is reflected in a very slowly rising Contraceptive Prevalence Rate (CPR) over the past decade and little change in demand indicators such as ideal family size and total fertility, despite considerable funding, limelight and resources. This review explores nationally available data to understand the causes for this limited success of family planning programming.

METHODS

This is a thematic review of Pakistan Demographic and Health Surveys 2007, 2012 and 2017, with some illustrative examples from other local studies or evaluations.

FINDINGS

National CPR changed from 30% in 2007 to 35% in 2012 and 34% in 2017 while CPR for modern methods changed from 22% to 25% and then remained unchanged. This corresponds to around 11.36 million users of FP but only 4.9 million that avail any family planning services each year - the rest had received a permanent or long-term method in a previous year. This means that only 15% of all Married Women of Reproductive Age (MWRA - i.e., married women between the ages 15-49) avail FP services each year - a proportion that has remained unchanged since 2007. Nearly half (44%) of all those who avail services buy a product directly from a store. The method mix is dominated by condoms and tubal ligation and does not change much by age, parity or when women say they want to space or limit children. Age of peak fertility remains in the 25-29 year bracket while age of peak family planning increased from 35-39 bracket to 40-44 in 2017. Although much of programming is supply driven, contraceptive supplies data do not match community uptake (as estimated from PDHS 2017) and mismatches vary from 16% to 1100% depending on the method.

CONCLUSIONS

Key factors in lack of progress are limited demand creation, a lack of response to women's preferences during service delivery and the lack of consideration of coverage in programmes. Current programmes serve around 4.9 MWRA each year while an additional 12.8 million women must be served annually to reach Pakistan's goal of 50% CPR. To do this, a number of changes are needed, including demand creation, community contextualized programming, more accurate data about programming and commodities, and better use of this data in making programming and allocation decisions.