ICRH Monographs Syed Khurram Azmat Models to accelerate modern family planning/contraceptive services access and uptake among married women in rural Pakistan


Dr. Syed Khurram Azmat successfully defended his PhD thesis entitled: “Models to accelerate modern family planning/contraceptive services access and uptake among married women in rural Pakistan” on Monday, January 9th 2017 at 12:00 on the UZ hospital campus, Ghent University, Belgium.


Dr. Moazzam Ali
Prof. dr. Marleen Temmerman



Executive Summary
In Pakistan, there is a clear imbalance between the population’s needs and available resources to cater for spacing and limiting childbirth as desired by couples. The Pakistan Demographic and Health Survey (PDHS) 2012-13 cited a mere 26% of married women of reproductive age (15-49 years) using any form of modern contraceptives, which is one of the lowest levels of modern contraceptive uptake in the South Asian region following Afghanistan.
In 2012, almost half (4.15 million) of an estimated 9 million pregnancies were unintended in Pakistan. Between 2002-2012, the unintended pregnancy rate soared from 71 to 93 per 1,000 women aged 15-49 – an estimated 54% (2.25 million) unwanted pregnancies ended in abortion, 34% (1.4 million) led to unplanned births and 12% (0.5 million) resulted in miscarriages. With the total population of Pakistan currently at 182 million, this presents a significant challenge.
In Pakistan, the public sector used to serve a significant proportion of the population. However, the private sector has progressively taken over health-care provision due to the prevailing bottlenecks in public sector – namely Access; Availability; and Quality. This is driven by lack of coverage, insufficient human resources, provider absenteeism and dual practice, poor infrastructure exorbitant informal fees and quality of care issues underpinned by lack of accountability (almost negligible monitoring and evaluation). All of this leads to low
utilisation of services in the public health system.
Less than 1% of Pakistan’s government expenditure on health is less than half the mean amount spent by comparison with neighbouring lower middle-income countries such as Bangladesh, India, Iran, Nepal and Sri Lanka. As a result, more than two-thirds (70%) of the Pakistani population are now paying out-of-pocket for overall health costs. Interestingly, with reference to the source of modern contraceptives in the South Asian neighbouring countries, the public
sector share is more than two times higher than that of the private sector. Likewise, both the public and private sectors also provide family planning (FP) services in Pakistan.
However, Pakistan represents a unique case in this region as the private sector has now overtaken the public sector in provision of FP services. The last three demographic surveys in 1990-91, 2006-07 and 2012-13 reported a significant decline in the public sector share of FP from 56% to 40% and then 35%, respectively. During the same period, private sector share presented an inverse reflection of the public sector and rose from 34% in 1990-91 to 42% in 2006-07, finally reaching 52% in 2012-13. This increasing reliance on the private sector is particularly prominent in rural areas where more than 30% of public sector-owned first-level care facilities are located. However, many of these facilities are not operating adequately – some of them are completely non-functional and the rest of them suffer from the non-availability of either trained staff or contraceptive commodities.
It is important to recognise that both the sectors are still falling short in addressing the population’s family planning needs. The shortcomings of the public sector in providing FP services have resulted in the development of integrated health financing models exclusively used to fulfil FP service requirements. These models are driven by enhancing access, uptake and quality of FP products and services in targeted populations and areas within Pakistan and elsewhere. For example, demand-side financing (DSF) schemes that aim to improve the delivery and uptake of contraception have been tested in low- and middle-income FP2020 priority countries. (Pakistan is a signatory of the global Family Planning 2020 pledge, which is to
provide services to 120 million new family planning users by the year 2020) Private sector DSF schemes incorporating FP service provision through vouchers have been shown to be effective in Ethiopia, India and Uganda, as well as Pakistan. These models work at four levels to achieve their goals: first, by improving access to FP products and services by providing either free or subsidised services; second, availability of services is enhanced by ensuring a steady supply of products; third, providers are imparted training in order to provide standardised care and ensuring quality of care; fourth, grassroots mobilisation efforts are undertaken to motivate end users to take up the FP services and products on offer.
This thesis is guided by a central aim to increase access and utilization of modern contraceptive in the underserved Pakistan and by the research question, “What are the effects of integrated health financing models for family planning on access and uptake among married women in rural Pakistan?” Eight studies are included, each using different methodologies and presenting key findings in relation to research objectives that were to examine the determinants associated with the uptake of modern family planning/contraceptive services in Pakistan in underserved areas. They test interventions related to integrated health financing models; assess various integrated health financing models (interventions) exclusively aiming to enhance FP access and uptake among married women in rural Pakistan and drive the formulation of recommendation for the development of health financing models that promote FP access and uptake for married women Our findings from the eight (08) papers in this thesis demonstrate that the use of integrated health financing private sector models – including: 1) targeting underserved communities through demand-side financing vouchers complemented by social franchise providers; 2) task sharing through community midwives: building public-private partnerships; 3) community health workers: connecting clients with the local facility; and 4) expanding outreach services to reach out to underserved communities – has a positive and favourable impact.
Our findings show that the provision of free contraceptives has increased through vouchers using a social franchise approach, - Intrauterine device (IUD) use by 11.8% (from 1.9% to 13.7%) and condom use by 6.0% – from 5.4% to 11.4% in the intervention group.
Additionally, there was a favourable impact on IUD discontinuation rates that averaged 19% at 12 months in the post-intervention period, which is lower than the national average of 26%. A separate study testing the effectiveness of a social franchise model supplemented with vouchers reported current contraceptive usage increase of 13.7% from 34.0% to 47.7%, with a 6% increase in IUD usage in the intervention group. Furthermore, qualitative research exploring barriers to accessing post-abortion services shows that, while seeking post-abortion care, women’s decision-making is influenced by household economics, views of husbands and in-laws, restrictions on female mobility, the views of religious clerics and a lack of transport.
Given the importance of FP in reducing high fertility, it would be in the best interest of women and girls and society in general to enhance FP programmes across the country that facilitate access to modern methods of contraception, as well as access to health-care facilities for sexual and reproductive health. A reduction in high fertility not only improves the health outcomes of women and families, it also benefits a country’s economy through an improvement in general health. In addition, an improvement in the ability to control fertility in Pakistan through public and private investment and cooperative effort would result in marked improvements in relation to   economy, health and inequity. In a recent evaluation, the Eastern Mediterranean Regional office of the World Health Organization (WHO) recognised the significance of the private health sector in most of the countries in its region, including Pakistan. However, due to lack of evidence it has not been possible to translate these critical attributes and the impact of private sector efforts into a knowledge-based strategy that helps to achieve public health goals in the Eastern Mediterranean Region countries such as in Pakistan.
To summarise, integrated health financing models exclusive to FP not only increase the uptake of modern FP services in underserved areas but also facilitate the long-term continuity of modern FP methods, as well as promoting method-specific switching behaviour. Such models using social franchising have a tangible effect on modern family planning uptake within communities. This in turn has a broader impact on the health of community members as a consequence of increased contraceptive use and reduced total fertility. It has been documented that the provision of evidence-based interventions and care packages especially for the rural population reaching 90% coverage (including approaches to promote post-abortion care; antenatal and postnatal care including family planning services) can contribute averting an estimated 58% of maternal, new-born and child deaths in Pakistan, and furthermore, 49% of stillbirths could also be prevented.
Government programmes have so far not had the desired impact on enhancing contraceptive uptake. Such models should be considered for adoption into government programmes and further use in future for establishing public-private partnerships in the provision of modern family planning/contraceptive services at the community levels.
Engaging private sector would have a significant impact on improving family’s lives and empowering vulnerable women in Pakistan.

Authors & affiliation: 
Dr. Syed Khurram Azmat
Published In: 
ICRH Monographs
Publication date: 
Monday, January 9, 2017