With a population of more than 200 million, Pakistan is ranked as the sixth most populous country in the world. High rates of population growth are largely the result of frequent childbearing or high fertility-often corresponding to high unmet need for family planning. With a contraceptive prevalence rate of only 35%, the total unmet need for FP services is at 25%. Maternal mortality rate is 350-400/ 100,000 live births. The current population growth rate is 2 percent. According to estimates, Pakistan will become the fifth most populous country in 2050 at its current rate of population growth (Government of Pakistan, 2013). This scenario presents a picture that could be devastating for the country’s already-scarce national resources. At present, the population density in Pakistan is 231 persons per square kilometer. Although birth and death rates have fallen in Pakistan over the past several decades, the decrease in death rate is much more rapid than the decrease in birth rate. Subsequently, life expectancy at birth has increased: from 63.4 years in 1981 to 66.5 years in 2013 for females and from 62.4 years in 1981 to 64.6 years in 2013, for males (Government of Pakistan, 2013). Rural population (% of total population) in Pakistan was last measured at 63.12 in 2013, according to the World Bank.
Pakistan has 71,000 nurses and midwives, 19,000 other health service providers and 126,000 physicians. For every 10,000 people, there are 5 midwives, one other health service provider and 12 hospital beds. 70% of healthcare is provided through the private sector. The public sector is large but does not work efficiently; problems occur with supplies and staffing, and facilities often tend to be poorly maintained. Frequent changes in government also lead to frequent changes in staff at all levels. Salaries within the government health sector tend to be low, while private practice is much more lucrative, hence preferred by most providers. Access to healthcare thus tends to be very expensive for the average Pakistani who relies on private sector facilities.
Rahnuma-FPAP and Greenstar Social Marketing, are leading organizations in Pakistan for family planning and contraceptives services. They play a significant role in providing access to family planning services for the poor; however their outreach tends to be primarily urban and semi-urban. There are several associations for private providers such as the Pakistan Medical Association, the Pakistan Nursing Council, the Pakistan Society of Obstetricians and Gynecologists, and the Midwifery Association of Pakistan. There is little interaction between private and public providers; however, due to recent efforts by the NGO sector, especially through advocacy with the Ministries of Health and Population Welfare, both at the Federal and Provincial levels, this picture is slowly changing. Many private providers who are also engaged in the NGO sector have begun interacting with senior officials within these Ministries to advocate for policy change and implementation. Nevertheless, relationships that are being developed between the private and the public sector are largely individual driven; for example, the current Health Secretary is supportive of public-private partnerships as are several senior officials within the Ministry of Population Welfare. If any of these individuals are transferred, there is no guarantee that their successors will be interested in continuing to build these relationships; thus, at present, public private relationships are being developed, rather than institutional public-private partnerships. The public sector, being the chief player in the health sector, cannot do much to turn around the situation in Pakistan, for it serves only 15% of total population of Pakistan. Whereas private sector caters to 85% of the population it contributes just 15% to all Family Planning services in Pakistan. It is thus the need of the hour to engage private health sector in the provision of FP and SRH services.
Rahnuma-FPAP, with its wide service delivery network, is one of the significant providers of SRH & FP services. Currently, services are provided through ten fully functional Family Health Hospitals, more than one hundred Family Health Clinics, and more than twenty five hundred Private Practitioners (PPs) and Community Based distributors (CBDs) across Pakistan. Rahnuma-FPAP’s SRH infrastructure is well-equipped to respond to the unmet need of family planning among the marginalized, poor and underserved men, women and youth. During 2015, Rahnuma-FPAP strived to double SRHR services provided, while focusing on social franchising and increased the number of aligned Private Practitioners (PPs) and Community Based Distributors (CBDs) across Pakistan. Comprehensive capacity building programs were carried out for these PPs and CBDs and provided them with different value added services, including sign boards, stationary and regular replanting of contraceptives, resulting in strengthening their performance and service provision for target communities. SRH referral mechanism at all levels was strengthened while enrolling new PPs, CBDs and TBAs. Regular follow up and coordination meetings were conducted, and contraceptives supplies, BCC and IEC material on SRH and FP were shared with them.
Rahnuma-FPAP also integrated SRH and HIV and AIDS prevention services at our selected SDPs. These Drop-In and VCT centers provided SRH and HIV & AIDS related services to target population groups, such as street based female sex workers, male sex workers, injectable Drug Users (IDUs). The SDPs established in Lahore, Quetta and Faisalabad provide SRH awareness, counseling and rehabilitation services with the collaboration of Provincial AIDS Control Programs (Punjab & Balochistan). BCC and IEC Toolkits were also disseminated among the above mentioned target populations to protect them from contracting STIs/STDs.