Contraceptives or Diapers, it’s really your choice..

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It’s interesting when a couple is baffled at the news of a recently discovered pregnancy, like it’s something that only happens when lightning strikes twice. Why are so many couples still adamant about not using Family Planning? As we look into the matter, it’s hardly a surprise why people end up having unplanned children all across Pakistan.

In Pakistan the trend of Family Planning has been increasing, albeit at a marginal rate of 0.5% per year. Out of 24 million married women of reproductive age (MWRA) only 7 million (29%) are using family planning versus 17 million women not using any contraceptive means to control pregnancy whatsoever. However, 6 million couples want to use Family Planning and yet don’t? What are the barriers between wanting to use and actual use?

Some thoughts –
The method mix for family planning services includes around 5 million women using the modern method and 2 million women using the traditional method. Condoms are the most widely used methods. The mean age for female sterilization is 39 and by this age women already have on average 6 children. To be effective Public health planners must promote the use of IUDs and female sterilization at a much earlier age.
The public sector only accounts for one-third of the FP services which are procured by women or couples directly, without any consultation. A large group of women have an Unmet Need (1 in 4), and this is a potential group that can be targeted for family planning services.
Historically, the demand side has been focused on but perhaps a much better strategy would be to increase supply of such services because if they are readily available, women will use them. Furthermore, public health planners should make their services accessible, associate with NGOs and private partnerships and provide consultation about usage and side effects.

Contraception is supposedly a controversial topic in Pakistan, but when talking to women in the communities it needs to be a priority topic. Clearly the topic is important to women and yet the decision makers are afraid of religious wrath. How can we promote a healthy debate on FP?
How can communities be helped to use Family Planning? What could be some innovative techniques to introduce a socio-cultural change in communities so they look at Family Planning measures favourably?

Anthony Downs: Brilliant Analysis of Political Actions in a Democracy

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Anthony Downs wrote this elegant analysis in 1957, which in my opinion remains a groundbreaking idea and is probably the best scientific paper I have read in years. Did I mention, its still very relevant to our times.

In it he says that a democracy is a political system with 2 or more parties. Within it, the parties act like enterpreneurs competing for votes rather than money. They sell their policies and therefore their policies are developed strictly with the aim to gain votes. Any social responsibility they have is secondary to this primary goal. Within a party individuals seek out personal gains (money, power, prestige…) by leveraging the position their party is in.

Governments make decisions differently in a world with imperfect information than they would in a world with perfect information. Lack of complete information upon which to vote is a given in human societies. Consequences of imperfect information are profound:

It means that since any given citizen can not know everything they need to know about the political system, some individuals are more important than others due to their special knowledge. Similarly, since the government itself is ignorant of what all that its citizens want, it must therefore send out representatives to citizens. This in turn turns a democracy into a representative government. It also means that it must develop specialists in specific items of information who then know disproportionately more than others and inform the government about these things. They can also lobby the government to make certain decisions over others, thereby acting as specialists in their areas of expertise. Their expertise makes them lobbyists and lobbyists therefore are intermediaries between the citizens and the government and can leverage their position for personal gains. In the same way, lack of perfect knowledge means that citizens must buy this information (or gain access to this information), thereby making a government party is susceptible to bribery to promote special interests.

It amazes me that Downs wrote this around 55 years ago and this analysis (and more to come in upcoming blogs) does not form the basis of more in depth analysis of the decisions we all live in.

Are Family Planning services in Pakistan actually declining

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While recent years have seen an increase in funding – at least from donors – into reproductive health in general and family planning in specific, the Government of Pakistan’s Contraceptive Performance Report which tracks the supply of FP services and commodities in the country, suggests that the supply of both commodities and services has actually declined by around 10% in the past five years.

The Contraceptive Performance Reports were published by the Ministry of Population Welfare until it was abolished in 2010. Since then the report is published by the Pakistan Bureau of Statistics and uses the records of the Central Warehouse that stores and supplies all contraceptive commodities in the country. According to the report, commodities and services were given to 4.1 million women in 2006-7. This figure declined to around 3.7 million women by 2010-11. Much of the decline is in the private sector while the public sector remained unchanged. More concerning is the fact that during this time approximately 2 million more Married Women of Reporductive Age (MWRA) were added to the denominator. If the report is accurate then the national CPR for modern methods which was around 22% in 2006-7 must have declined to around 17-18%.

But, is the report accurate. For example, the Marie Stopes Society was not a major provider in 2006-7 but report serving 1.1 million women in 2010-11. The Contraceptive Performance Report however attributes only around 20-30 thousand women served to MSS.

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Back it up with evidence

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Evidence based policy making is any level of public, economic or health relevant policy making which is established based on some sort of objectifiable evidence that can support the policy. The purpose of it is to keep identifying newer programs and practices that are capable of enhancing the outcomes of the relevant policy. Health and Development Programs, Policy and Funding must be informed with quality evidence. In a country such as Pakistan that is struggling to meet its Millennium Development Goals needs to institutionalize a culture of evidenced based policy making to improve its social development indicators. Often data exist to develop the evidence base needed to inform funding and developing initiatives and yet remain unused because of time, capacity or other constraints.

How can we work towards institutionalizing a culture of evidence based policy making in Pakistan?

Who should be the stakeholders and initiators?

How should things be initiated?

What are some of the expanded reasons to explain why it is critical?

Most Family Planning services in Pakistan are actually self procured by women….

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According to the Pakistan Demographic Demographic Survey 2006-7, over half of the women who use a modern contraceptive, bought their method directly from a shop or chemist.

The survey showed that the proportion of married women 15-49 years old that use family planning increased from 12% in 1990 to 30% in 2006-7. This comes to around 7 million women that use some form of family planning. 5 million of these are using a modern method, although around half of these have either received sterilization or an IUD. Since many of these women received these in previous years, actual women who avail family planning services in any given year are around 3 million or 12% of all married women 15-49. 52% of these buy their own supplies without using the services of a health provider and therefore potentially miss out on counseling.

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Women availing Family Planning Services in any given year are around 12% of all MWRA

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Family Planning Programs in Pakistan started in the mid-1960s and have tried many initiatives and policies. And yet the current contraceptive prevalence rates (CPR) stand at 30%, reflecting around 0.5% annual increase since the start of the family planning programs in 1964.

Approximately 30% of women report using some form of family planning. 22% use a modern and 8% use a traditional method. This means that of the nearly 24 million married women of reproductive age (MWRA), approximately 5 million women use a modern method and nearly 2 million women use a traditional means and a staggering 17 million do not use any family planning at all. These 17 million include around 6 million women have an unmet need for family planning. Since 38% of all modern method users are sterilized – 91% before the past 12 months – and 10% have an IUD, the actual number of women that avail FP services are around 3 million or 12% of MWRA.                                    More…   Also…