Project assistance completion report : population welfare planning (391-0469)

The project proved that contraceptive prevalence rates can be greatly increased in Pakistan, but the financial and institutional commitment of the GOP is not sufficient to sustain this achievement without assistance. The contraceptive procurement component, on which nearly two-thirds of project funds were spent, met the PWP's entire need for contraceptives up until the early 1990s and ensured the availability of at least a 1-year supply of contraceptives at all times. Other notable achievements included institutionalization of a contraceptive logistics management system, establishment of a central warehouse, nationwide distribution of a contraceptive logistics manual and training in its use, and in-country training and third country study tours for mid- to senior-level managers. The institution-building component strengthened Pakistani research capacity by establishing the semi-autonomous National Institute of Population Studies, which produced a number of important studies, including the State of the Population in Pakistan (1987) and the Pakistan Demographic and Health Survey 1990/91. This component also supported efforts of the National Research Institute for Fertility Control and operations research for program monitoring and evaluation. Training efforts had mixed results. On the positive side, the training of over 8,000 health workers in 1,800 facilities helped to integrate FP service delivery into the national health care system, and helped 3 women's NGOs to establish a national NGO training organization which strengthened women's managerial and technical skills. On the negative side, professional training, especially graduate training, lagged severely, due more to the project's design than to its implementation. In addition, the NGO Coordinating Council (NGOCC), which had been initiated with project assistance and which during the project increased its members from 9 to 126 and its service delivery outlets from 93 to 563, foundered when project funding was withdrawn. The IEC component helped the GOP to launch a FP communication strategy and plan of action which spurred an unprecedented partnership between population planners and media professionals, resulting in "Aahat," the nation's first FP social drama, as well as radio, TV, and newspaper spots, and seminars for policymakers and media professionals. These efforts increased positive attitudes toward FP from 65% to 75% and affected the FP behaviors of about 10% of those who watched the series. Finally, the service delivery component supported the efforts of 77 NGOs which operated over 200 service outlets providing about 650,000 couple-years of protection annually. It also successfully tested 30 community-based distribution models which have led to the most dramatic results of any FP project in Pakistan, increasing contraceptive prevalence rates in 6 pilot areas from 11.5% to 39%. Training of 349 doctors and nurses in voluntary surgical contraception (VSC) and counseling significantly increased provision of VSC. The following lessons were learned. (1) Strong and unwavering political commitment is a prerequisite to a successful FP program. (2) The PWP's highly centralized and politicized infrastructure greatly reduced its efficiency and effectiveness. (3) NGOs will continue to play a vital role in FP in Pakistan. (4) To be effective, an NGO coordinating body must become a legally constituted organization, independent of government interference. This was not the case with the NGOCC. (5) Well-planned and well-implemented community-based programs can be as successful in Pakistan as elsewhere in South Asia; in this project they raised the contraceptive prevalence rate to about 40%, a level nearing that of Bangladesh, in under 2 years' time. (6) Integration of FP into primary health care through the existing health network is critical because it increases FP acceptability. (7) A woman-to-woman approach increases the accessibility and acceptability of FP services in restricted societies. (8) The allocation of so much funding for contraceptive procurement left little for institution building, management training, IEC, and counseling. (9) The method mix remained much too weighted toward condoms and other less effective methods. In this connection, it is noteworthy that, apart from voluntary surgical contraception (VSC), which is unavailable at most MOH health units, clients who attended these units appeared to select more effective contraceptive methods (e.g., injectables, IUDs, and orals) than those attending FP centers. (10) Operations research (OR) is a quick, flexible tool for resolving program barriers. In this project, small OR studies produced results that led to changes in target setting, method mix, staffing for service facilities, and training of village workers. As for sustainability, while the project contributed in some areas, it failed in others, principally in developing the public sector's capacity to provide effective clinical methods, conduct IEC, and implement training programs. The project also failed in two areas important to financial sustainability -- development of cost recovery strategies and of a plan to free the GOP from reliance on donated contraceptives. This was evident from the severe cutbacks NGOs were forced to take when USAID funding ceased. However, NGOs now report that they have learned their lesson: they have been somewhat successful in diversifying their resource base; they have been creative in getting corporate commitments for services or products; and they have accepted the concept of fee for service. Likewise, the GOP has developed its tender procedures for procuring contraceptives and has recognized that revenues generated from contraceptive sales can be used for refilling supplies.