Policy Brief

Slow progress of Family Planning

in Pakistan and possible Learnings
from the successful experiences of
Iran, Turkey and Bangladesh

1 BACKGROUND
Pakistan’s population is estimated to be remained unattained. The existence of
220.9 million (mid 2020), growing at 2.1 unmet need for contraception (17% of population - PAKISTAN
percent per annum and with net annual married women) and continued persistence
addition of 4.3 million, it is projected of inequity among users reported by 2017- MID 2020 2030
to touch 263 million by 20301. The 18 PDHS reflected in major difference of (Estimated) (Projected)
rapid population increase has several use of modern contraceptives between
220.9 263
1
implications for the socioeconomic poor and rich segments of married women
development of the country. As one of the (13 point difference) points to weaknesses
few pioneer countries, Pakistan visualized in the service delivery system. The non-use
million million
this situation in the 60s and took a policy of contraception and high unmet need have
decision to address population issue by resulted in high-risk births at times leading
introducing voluntary family planning to unsafe abortions. A study undertaken modern contraceptive methods
services in the country. However, with five- by Population Council in 20123 estimated
decades of investment in family planning that 2.25 million induced abortions were
program, only 25 per cent of women performed directly affecting the highly only 25%
reported using modern contraception in sensitive health indicator of maternal of women reported using
2017-18, the lowest amongst the Asian and mortality ratio (MMR). Though this has modern contraception in
neighboring Muslim countries. With family declined over the last decade (from 276 to 2017-18
planning programme in place, Pakistan 186 for 2006-07 and 2019), but still much
aimed to achieve replacement level higher than neighbouring Muslim countries.
fertility (2.2 births per woman by 2030).
The Third Meeting of the Federal Task Force
FERTILITY RATE - PAKISTAN
Fertility declined steadily from 4.9 births
(held on August 6, 2020), Chaired by H. E. Dr
per woman (1990-91 PDHS)2 to 4.1 births
(2006-07 PDHS) and to 3.6 births (2017-
Arif Alvi, President of Pakistan who took note
of the unusual slow pace and low uptake
PAKISTAN AIMED to
achieve replacement
2.2
births per
18 PDHS). Surveys reveal that fertility level fertility women by 2030
of family planning in Pakistan desired to
decline generally remained slow after 2006.
know the reasons of this situation and how
Pakistan is falling behind to achieve its
own goals set for lowering fertility reflects
Pakistan can take benefit from successful
experiences of three Muslim countries –
1990-91
PDHS
4.9
inadequate investment and attention to births per woman
Iran, Turkey and Bangladesh. This brief
raise contraceptive use rate.
According to population Policy 2002
provides a comparison of major features of
four nations to show where Pakistan stands,
2006-07
PDHS
4.1
births per woman
Pakistan envisioned to achieve what best practices were implemented by
replacement level fertility by 2020. Pakistan these nations to address high growth rate,
pledged at the 2012 London Summit on and how Pakistan can take advantage from 2017-18
PDHS
3.6
Family Planning to achieve a CPR level of their successful experiences. births per woman
50 percent by 2020. But both the goals

1
Elaboration of data by United Nations, Department of Economic and Social Affairs, Population Division.
World Population Prospects: The 2019 Revision.
2
Prior to the 1990s, average fertility in Pakistan was approximately six births
3
“Induced Abortions and Unintended pregnancies in Pakistan, 2012” - Population Council 1
 2 Population and Family Planning Programmes of Turkey, Iran and Bangladesh

Pakistan Turkey Iran Bangladesh

initiation OF POPULATION
AND FAMILY PLANNING
PROGRAMMES 1965 1965 1989 1976

It is interesting to note that all three Muslim late 1980s already had achieved TFR of
countries initiated their population and 3.4 births. Iran’s progress has been most Bangladesh is a remarkable example
family planning programs almost at the dramatic in the increase of modern CPR of rapid increase in contraceptive use
same time or even later than Pakistan’s – doubled from 27 to 56 in just 12 years and fertility decline during mid-1970s
policy declaration: Pakistan – 1965, Turkey (1988 to 2000). Iran’s fertility declined to late 1990s when TFR declined from
– 1965, Iran – 1989, Bangladesh – 1976. by more than half in ten years, from an 6.3 to 3.3 births and modern CPR
The figures below present the trend of total average of 6.2 births per woman in 1986 to increased from 5 to 43 percent. The
fertility rate and contraceptive prevalence 2.5 births per woman in 2000 particularly stalling of fertility in Bangladesh for
rate in each of these four countries. impressive in rural areas4. Studies show a decade was taken as a challenge
Turkey achieved 40 points increase in that 61% of the reduction in fertility rate in and addressed through series of
CPR in 2 decades (1963 – 83) but had Iran was attributable to family planning5. programmatic modifications to
high proportion of traditional method use achieve desired fertility level of 2.1.
complemented by abortion rate and by

Trends of Fertility and Modern Contraceptive Use in Turkey, Iran, Bangladesh, and Pakistan
Trend of TFR and mCPR - Turkey Trend of TFR and mCPR - Iran

Trend of TFR and CPR in Bangladesh Trend of TFR and CPR - Pakistan

4
Farzaneh Roudi, Pooya Azadi, and Mohsen Mesgaran. Iran’s Population Dynamics and Demographic Window of Opportunity,
Working Paper 4, Stanford Iran 2040 Project, Stanford University, October 2017
5
Erfani A, McQuillan K. Rapid fertility decline in Iran: analysis of intermediate variables. J Biosoc Sciences 2008; 40:459–78.

2
 3 Essential Elements of Success in three Muslims Countries
The critical features adopted by the three countries to achieve success are:

1 Legislation and Passing of a Law by Parliament in Turkey (in part of development planning and social
1965 and 1983) and Iran (in 1989) laid the reforms. Firm political commitment upheld
Parliamentary foundation of Population Planning and Policy the establishment of long-term plans and to
support to pursuit. Open discussion among members providing necessary funding to implement all
reflect political and Politicians built ownership especially in aspects of the plans. Critical to their success
commitment Iran when senior religious leadership issued was the ‘open support and seriousness’
Fatwa and began to give Friday sermons, expressed by the leadership towards the issue
which produced tremendous acceptance to convey determined message to program
of the concept of small families and use functionaries and people in general to pursue
of contraception. The Law provided legal the goal. Leadership’s unwavering support and
framework for funding and to take measures clear understanding of population as a national
for nationwide family planning program, cause on long term basis, and persistence
with focus on reaching out at doorsteps with patience even with changes in political
with modern contraceptive methods. In governments, were considered key factors for
Bangladesh, Population Policy was formulated the results.
in 1976 and approved by the Cabinet as integral

2 Comprehensive Open political commitment, with firm and modern contraceptives, and addressing
serious support of the leaders sustained over their misgivings and fears. The uniqueness
Plan for universal time was translated into a thorough Plan to regarding Iran’s motivation and Program was
coverage and ensure widespread availability of information their three objectives: encourage birth spacing
Availability of and services along with a strong behavior for 3-4 years; discourage pregnancies before
change communications to educate and age 18 and after age 35; and encourage
services convince people. Commonalities among families for three healthy children. Bangladesh
them also included: establishing a national specifically evolved communication program
program under the Ministry of Health to address desire for large family size and
responsible for implementing family planning son preference, campaign also contributed to
initiatives; and all aiming at reaching women the success of the program. Strict program
at their doorsteps: regional mobile teams in monitoring, use of operations research and
Turkey, community-based health workers evaluation to address program weaknesses
and health houses in Iran; and family-welfare contributed significantly. Innovative initiatives
assistants in Bangladesh. The purpose in especially in Bangladesh during a decade of
each case was to educate women regarding status quo in fertility, enabled the country to
benefits of lower fertility, birth spacing, and go back on track to achieve a TFR of 2.1 in the
giving them necessary information regarding next decade.

3 Provision of Provision of a comprehensive package of public sector health personnel and facilities for
modern methods remained fundamental to the provision of FP services. Turkey used the
modern methods ensure proper birth spacing and minimizing 1965 Law on Population Planning to mandate
and integrating unintended or untimely pregnancies. and direct all health personnel of Ministry
FP services to Promotion of IUCD (in Turkey); and IUCD and of Health to provide FP services and later in
vasectomy (in Iran); and tubal ligation and 1983 authorized trained non-physicians to
broaden maternal injectables and emergency contraceptives (in provide IUCD that doubled IUCD use by 1988.
and child health Bangladesh) made real difference in reducing Iran, besides expanding the network to reach
services fertility. Furthermore, the role of ‘state taking out women also ensured primary health care
the driving force’ was essential to determine the setup to provide FP services. Bangladesh used
direction and to maintain momentum ensuring maternal and child health framework post-
needed contraceptive method mix is attained approval of 2004 Policy whereby FP services
and is aligned with the fertility lowering goals were integrated with Primary Health Care for
while still ensuring client’s choice. Common easy of accessibility to women.
to all three countries was the proactive use of

4 Pursuit of female Girls education works several ways to as development objective over the years, which
influence attitudes and behaviours especially not only helped in increasing age at marriage,
education goals when seen in context of female autonomy, but also promoted desire for smaller family
social equity, understanding of family building and minimized son preference as a factor for
and use of contraception for birth spacing. All more fertility.
three nations actively pursued girl’s education

3
 FactorS Contributed to low uptake of family planning in Pakistan and key
4 lessons from the three countries:
Several major issues and missed opportunities may be noted for low uptake of family planning in Pakistan:

1 Rapid population growth though accepted as a barrier to of differences in sources of funding, fund flows, hierarchical
developmental since 1960s but never openly discussed in relationships, constitutional prerogatives and reluctance on
the parliaments or legislation ever evolved. Furthermore, part of functionaries5. Half-hearted response by all provincial
shyness of leadership towards open support and seriousness Departments of Health never integrated or implemented FP
for sustained efforts with consistency and continuity marred services with MCH in real spirit of commitment.
all desired long-term gains. Absence of leadership’s frontal
public statements and guidance allowed conservative forces 5 Role of state towards ‘policy review’ and ‘regulatory tasks’
to establish confusions and fears among people, which were remained non-existent6 at federal and provincial levels. Good
not allayed by direct contacts and education efforts. understanding and developing improved assessment of
progress and coordination with partners are critical for timely
2 High population growth was always seen as a competing reaching the goal.
priority against economic and development strides. Political
leaders and programme managers lacked understanding 6 Contraceptive method mix of Pakistan is acknowledged for its
and patience necessary to pursue the cause of population least efficacy and effectiveness towards lowering fertility since
on sustained basis and wait for the result. Leadership and 1990s. Focus on tubal ligation and condoms have contributed
management also shied from progress review at the federal least towards this goal. Though about half of all women reach
and provincial hierarchy reflecting lack of empathy. out to private sector for services due to their easy access and
active role in promoting contraception but remained limited to
3 Though service delivery and counseling at community level least effective methods.
was given credence in mid 1990s but ever since year 2000 it
is not taken with seriousness to be followed up for assurance 7 Quality of services monitoring, and beneficiary feedback
and appreciation. Counseling women played a critical role in all remained secondary and lacked intensity.
three Muslims countries (Turkey, Iran & Bangladesh) to educate 8 Performance Evaluation and Research was a Programme
and encourage clients and address fears and myths of family pillar but not given adequate institutional support to address
planning and contraceptive technology. Unfortunately, it never and analyze substantive field problems. Inadequate support
received adequate attention by all stakeholders in Pakistan to the pillar led to decay of research institutions in terms of
especially after dilution of the tasks of LHWs in year 2000 and research capacity and its contribution to the sector.
beyond in support of other health programmes.
9 The devolution of functions in 2010 diluted the national cause
4 Provision of FP services within healthcare umbrella and has not improved but contributed to further neglect of the
provided boost to service acceptability in all three countries. importance in real terms. The spirit of devolution in terms of
Unfortunately, delivery of FP services by the Population Welfare building capacity and authorizing districts for planning, action
and Department of Health (solely and together) did not fully and accountability lacked seriousness.
meet the needs of the people mainly because of silo approach
and lack of coordination and collaboration. Merger of the 10 Female education though considered a critical pillar to social
two Ministries have been the agenda of several government’s change and a major factor in fertility decline yet was not given
since year 2000 but it remained a difficult proposition because carefully attention and to enhance investment since year 2000.

5 Way forward on all socio-economic development sectors.

We should sensitize and empower political
recommendations must be reviewed and
steps taken to realize it.
leaders and the bureaucrats and follow up
progress through a strong accountability 5. Investment and promotion of birth
In view of existing barriers and to achieve
mechanism. spacing methods like IUCDs and implants is
the goal to further decrease fertility rates overdue and needs greater attention.
by 2030 (as pledged at ICPD 25 and 3. All provincial Health Outlets must
Nairobi Conference Nov 2019) and based take on FP as integral service with full 6. Equity must be a key strategy in future
on the successful experiences of the three commitment. Strengthen LHWs and other plans to enhance access to the poorest
Muslim countries, following key measures CHW programme supplemented by other segment of population and promoting a
are outlined: interventions such as male engagement, method mix that builds birth spacing and
premarital counseling, encouraging minimizes unintended pregnancies
1. Political Commitment and voice needed
to be raised in Legislation with persistence female education and life skills based 7. Counseling and services go as a package
and continuity. Sustained engagement of education for young people to learn – but private sector remained focused on
legislators for championing and holding the benefits of family planning. Immediate services and sales. Media should actively
executive accountable. high-level conversation and decision to promote FP messages.
come up with a more cost effective and
2. Population should remain a national expanded family planning programme 8. Research and Evaluation by made essential
cause and provincial contribution evolved by ensuring provision of family planning part of policy revision. Strong M&E system
by consensus and funds made available services as part of broader maternal and supported by availability of reliable service
by provincial and federal government with family health services by DoH. coverage data and frequent representative
understanding of long term need and patience surveys such as the Performance, Monitoring
to wait for the results being critical due to 4. Annual policy Review System must be for Action (PMA) and operations research are
crosscutting effect of the population variable established at national and provincial needed.
leadership levels. Implementation of CCI

6
Sania Nishtar, Saba Amjad. 2009. Pakistan’s health-population mantra J Pak Med Assoc. Vol. 59, No. 9 (Suppl. 3), September

ACKNOWLEDGMENTS This policy brief was prepared by National Institute of Population Studies (NIPS) and
the Ministry Of National Health Services, Regulations and Coordination - Government
of Pakistan, with technical and financial support from United Nations Population Fund
4 (UNFPA) Pakistan. Special Thanks to Dr. Tauseef Ahmed, UNFPA and NIPS Consultant.