Family Planning Compliance Monitoring: Pakistan Technical Brief

Despite being the first country in the region to initiate a family planning (FP) program in the 1950s, Pakistan lags behind its neighboring countries in birth rate reduction. The contraceptive prevalence rate (CPR), or percentage of married women or men of reproductive age using FP methods at a particular point in time, is 34%, increasing at a slow rate of 0.5% annually. The Pakistan Demographic and Health Survey 2017-18 reported a 52% demand for FP and a 17% unmet need. The government of Pakistan pledged to achieve universal access to reproductive health services and to increase the CPR from 35% to 50% by 2020. With donor support, the country accelerated the provision of voluntary FP services, introducing new effective interval and postpartum FP methods, including subcutaneous depot medroxyprogesterone acetate and long-acting reversible contraceptives. Task-sharing initiatives were also piloted among FP service providers to enhance provider efficiency and client access to services. However, the push to achieve these projections posed the potential for vulnerabilities in maintaining the FP principles set by the US Government of voluntarism and informed choice (V&IC) at the time of service provision. The US Agency for International Development (USAID)'s flagship Maternal and Child Survival Program (MCSP) worked in Sindh, Balochistan, and Punjab provinces to improve accessibility, availability, and use of FP services, especially in underserved communities. MCSP implemented innovative approaches to strengthen the capacity of provincial departments of health (DOHs) and population welfare departments (PWDs) in providing FP services and enforcing the principles of V&IC in FP service provision. A robust FP compliance monitoring mechanism was developed to ensure every client was able to make voluntary and informed reproductive health choices. The FP compliance monitoring model follows two steps: initial development and routine monitoring. Initial development involved assessing 50 select facilities across two provinces on their level of adherence to the principles of V&IC in FP service delivery. The assessment findings and analysis helped MCSP conceptualize and devise an effective and efficient compliance monitoring model. Planning involved consultations with both departments (DOH and PWD) to develop the monitoring mechanism, including a checklist, reporting tools, and follow-up processes. Workforce development involved building the capacity of district FP compliance monitors in both departments (DOH and PWD) to enhance their understanding of FP principles of V&IC. These district FP compliance monitors involved in overall monitoring functions in their department gained an in-depth understanding of FP compliance principles. Routine monitoring involved conducting joint monitoring visits at facilities, including in-depth interviews with facility-based service providers, group discussions with lady health workers, direct observations of client-provider interactions, exit interviews with clients, and debriefing meetings with relevant district officers. Implementation of MCSP's FP compliance monitoring model resulted in the following: all interviewed service providers demonstrated an in-depth understanding of the principles of V&IC. Repeated monitoring visits found all visited health facilities to be compliant with the FP principles of V&IC. The monitoring team developed and shared detailed reports, laying out a road map to address identified needs, such as trainings/refreshers for service providers; information, education, and communication (IEC) materials; and sufficient levels of stocks at health facilities. The advisory group proposed action plans to the relevant departments to address identified needs and established follow-up mechanisms to track progress in ensuing quarterly meetings.