Health Systems & Policy Department, Health Services Academy, Islamabad, Pakistan
Background Family Planning (FP) program in Pakistan has been struggling to achieve the desired indicators. Despite a well-timed initiation of the program in late 50s, fertility decline has been sparingly slow. As a result, rapid population growth is impeding economic development in the country. A high population growth rate, the current fertility rate, a stagnant contraceptive prevalence rate and high unmet need remain challenging targets for population policies and FP programs. To accelerate the pace of FP programs and targets concerned, it is imperative to develop and adopt a holistic approach and strategy for plugging the gaps in various components of the health system: service delivery, information systems, drugs-supplies, technology and logistics, Human Resources (HRs), financing, and governance. Hence, World Health Organization (WHO) health systems building blocks present a practical framework for overall health system strengthening.
Methods This descriptive qualitative study, through 23 in-depth interviews, explored the factors related to the health system, and those responsible for a disappointing FP program in Pakistan. Provincial representatives from Population Welfare and Health departments, donor agencies and non-governmental organizations involved with FP programs were included in the study to document the perspective of all stakeholders. Content analysis was done manually to generate nodes, sub-nodes and themes.
Results Performance of FP programs is not satisfactory as shown by the indicators, and these programs have not been able to deliver the desired outcomes. Interviewees agreed that inadequate prioritization given to the FP program by successive governments has led to this situation. There are issues with all health system areas, including governance, strategies, funding, financial management, service delivery systems, HRs, technology and logistic systems, and Management Information System (MIS); these have encumbered the pace of success of the program. All stakeholders need to join hands to complement efforts and to capitalize on each other’s strengths, plugging the gaps in all the components of FP programming.
Conclusion All WHO health system building blocks are interrelated and need to be strengthened, if the demographic targets are to be achieved. With this approach, the health system shall be capable of delivering fair and responsive FP services.
Bongaarts J. Can Family planning programs reduce high desired family size in Sub Saharan Africa? Int Perspect Sex Reprod Health 2011; 37: 209-16.
Byrne A, Morgan A, Soto J, Dettrick Z. Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research. Reprod Health 2012; 9: 1-13. doi: 10.1186/1742-4755-9-27
Shaikh BT, Azmat SK, Mazhar A. Family planning and contraception in Islamic countries: A critical review of the literature. J Pak Med Assoc 2013; 63: 67-71.
Streatfield P, Kamal N. Population and Family Planning in Bangladesh. J Pak Med Assoc 2013; 63: 73-81.
Simber M. Achievements of Iranian family planning programmes 1956-2006. East Mediterr Health J 2012; 18: 279-86.
Pakistan Bureau of Statistics. Contraceptive Performance Report 2011-2012. Islamabad; 2012.
National Institute of Population Studies & ICF International. Pakistan Demographic and Health Survey 2012-13. Islamabad; 2013.
Gazdar H, Khan A, Qureshi S. Measuring the economic costs of unsafe abortion mortality and morbidity in Pakistan: Preliminary findings and survey design. Karachi: Collective for Social Science Research; 2010.
Nishtar S, Amjad S, Sheikh S, Ahmad M. Synergizing health and population in Pakistan. J Pak Med Assoc 2009; 59: S3-23.
Shaikh BT. Unmet need for family planning in Pakistan- PDHS 2006-2007: It’s time to re-examine déjà vu. Open Access Journal of Contraception 2010; 1: 113-8. doi: 10.2147/OAJC.S13715
Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012; 380: 111-25. doi: 10.1016/s0140-6736(12)60478-4
Sami N, Shaikh BT. Leadership in family planning & reproductive health: a university based capacity building and networking initiative in Pakistan. Pak J Public Health 2012; 2: 46-51.
United States Agency for International Development (USAID). Deliver Project Task Order 4. Pakistan: Provincial and district supply chain management situation assessment. Arlington: USAID; 2012.
Wazir S, Shaikh BT, Ahmed A. National program for family planning and primary health care Pakistan: A SWOT analysis. Reprod Health 2013; 10: 60. doi: 10.1186/1742-4755-10-60
Backman G, Hunt P, Khosla R, Jaramillo-Stouss C, Fikre BM, Rumble C, et al. Health Systems and the right to health: an assessment of 194 countries. Lancet 2008; 372: 2047-85. doi: 10.1016/s0140-6736(08)61781-x
Shaikh BT. Devolution in health sector: challenges and opportunities for evidence based policies. LEAD Pakistan Occasional Paper Series. Islamabad; 2013.
World Health Organization (WHO). Strengthening Health Systems to Improve Health Outcomes. Geneva: WHO; 2007.
Shiffman J. Political management in the Indonesian family planning program. Int Fam Plan Perspect 2004; 30: 27-33. doi: 10.1363/3002704
Khanna A, Pradhan J, Rashid HA, Beekink E, Gupta M, Sharma A. Financing reproductive health in Bangladesh. J Health Manage 2013; 15: 177-202. doi: 10.1177/0972063413489004
United Nations Population Fund (UNFPA). The state of family planning in Pakistan. Targeting the missing links to achieve development goals. Islamabad: UNFPA; 2013.
United States Agency for International Development (USAID). IFPS Technical Assistance Project (ITAP).20 Years of the Innovations in Family Planning Services Project in Uttar Pradesh, India; Experiences, Lessons Learned and Achievements. Gurgaon, Haryana: USAID; 2012.
Hardee K, Leahy E. Population, fertility and family planning in Pakistan: a program in stagnation. Pop Action Int 2008; 3: 1-12.
United States Agency for International Development (USAID). Deliver Project Task Order 1 and Pathfinder International. Contraceptive Security Brief: Engaging Service Delivery Providers in Contraceptive Security. Arlington: USAID; 2010.
Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, França GV, et al. Equity in maternal, newborn and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012; 379: 1225-33. doi: 10.1016/s0140-6736(12)60113-5
Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I. Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011; 118: 78-87. doi: 10.1111/j.1471-0528.2011.03115.x
Nishtar S, Boerma T, Amjad S, Alam AY, Khalid F, Haq I, et al. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013; 381: 2193-206. doi: 10.1016/s0140-6736(13)60019-7
Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, new born, and child survival. Lancet 2010; 375: 2032-44. doi: 10.1016/s0140-6736(10)60678-2
Chikvaidze P, Madi HH, Mahaini RK. Mapping family planning policy and programme best practices in the WHO Eastern Mediterranean Region: a step towards coordinated scale-up. East Mediterr Health J 2012; 18: 911-9.