Executive Board
of the	Distr. GENERAL
United Nations
Development Programme	DP/FPA/PAK/6 8 July 1999
and of the
United Nations	ORIGINAL: ENGLISH
Population Fund

Recommendation by the Executive Director
Assistance to the Government of Pakistan

* As contained in document DP/FPA/1996/15 and approved by the Executive Board in decision 96/15.

¹ WHO, Coverage of Maternal Care, 3rd ed., 1993. Data cover the period 1983-1993.

³ UNICEF, The State of the World’s Children, 1995. Data cover the period l985-1993.

⁵ UNICEF, The State of the World’s Children 1995, which is based on data compiled by WHO. Data cover the period l980-1992.

⁷ UNESCO, 1996, Education for All: Achieving the Goal: Statistical Document.

Two dashes (--) indicate that data are not available.
 

Sources: Data are from the Population Division, Department of Economic and Social Affairs of the United Nations, World Population Prospects: The 1998 Revision; Urban and rural data, for 2000-2005 are from United Nations, World Urbanization Prospects: The 1996 Revision; GNP per capita is from the World Bank. Two dashes (--) indicate that data are not available.  

NB. The data in this fact sheet may vary from the data presented in the text of the document.  
 

1. The United Nations Population Fund (UNFPA) proposes to support a population programme over the period 2000-2003 to assist the Government of Pakistan in achieving its population and development objectives. UNFPA proposes to fund the programme in the amount of $35 million, of which $28 million would be programmed from UNFPA regular resources, to the extent that such resources are available. UNFPA would seek to provide the balance of $7.0 million from multi-bilateral resources and/or other, including regular, resources to the extent possible, consistent with Executive Board decision 96/15 on the allocation of UNFPA resources. This would be the Fund’s sixth programme of assistance to Pakistan.  

2. The proposed programme was formulated in close consultation with governmental, non-governmental, donor and United Nations organizations and takes into account the development objectives of the Government’s Ninth Five-Year Plan and the priorities of the Social Action Programme (SAP). It is based on the recommendations of the UNFPA Country Population Assessment (CPA) conducted between August 1998 and February 1999, under the leadership of a national steering committee with the assistance of a team of national experts and UNFPA Country Support Team (CST) advisers. To ensure harmonization with the UNDP and UNICEF programmes, the proposed programme will last four years and will end at the same time as the programme cycles of UNDP and UNICEF. The UNFPA country office will collaborate with the United Nations Country Team to prepare for and participate in the Common Country Assessment (CCA) and the United Nations Development Assistance Framework (UNDAF) exercises as planned.  

3. The Government of Pakistan is fully committed to a holistic approach in dealing with reproductive health and gender issues. The Ninth Five-Year Plan clearly endorses a comprehensive reproductive health approach and recommends the full integration of a service delivery network of population with health service outlets, including at district level and downwards, for the provision of reproductive health services, including family planning (hereinafter RH/FP). It also undertakes to improve and strengthen coordination among line departments and encourages greater involvement of non-governmental organizations (NGOs) and the private sector in undertaking innovative activities, disseminating information and delivering family planning services with a focus on reproductive health.  

4. The goal of the proposed programme would be to contribute to improving the quality of life of the people of Pakistan, including enhancing the reproductive health status of women, men and adolescents; promoting reproductive health and reproductive rights, and gender equity and equality; and achieving sustainable development in the context of the Government’s Ninth Five-Year Plan.

5. The proposed programme was developed within the framework of a human rights approach. All activities under the proposed programme, as in all UNFPA-assisted activities, would be undertaken in accordance with the principles and the objectives of the Programme of Action of the International Conference on Population and Development (ICPD), which was endorsed by the General Assembly in its resolution 49/128.    

Background  

6. According to the 1998 population census, the total population of Pakistan was estimated at 130.6 million and the annual population growth rate was estimated to be 2.4 per cent. Pakistan is the seventh most populous country in the world. The major factor contributing to the population growth has been the sustained gap between low mortality and high fertility levels over the last three decades. Although life expectancy at birth increased to 64.6 years in 1996, infant and child mortality rates, respectively at 95 and 137 per 1,000 live births, remain among the highest in the world. Maternal mortality is estimated to be 340 per 100,000 live births. The most common causes of maternal mortality in Pakistan, as in many developing countries, are preventable.  

7. While knowledge of contraceptives has become almost universal (94.3 per cent), the increase in contraceptive use has been slow. The contraceptive prevalence rate increased from 5.5 per cent in 1968 to 23.9 per cent in 1997. However, the unmet need for contraception remains high having risen from 28.1 per cent in 1990 to 37.5 per cent in 1997. The decline in the total fertility rate from 6.0 children per woman in 1985 to 5.3 in 1997 indicates the onset of a fertility transition in Pakistan. Since 1981, the median age at first marriage has increased slightly to 26 years for men and 22 years for women. However, pregnancy amongst married teenage girls is relatively high and, according to the 1997 Pakistan Fertility and Family Planning Survey, between 13.9 and 20.5 per cent of all live births in the country are accounted for by teenage mothers.

8. Pakistan ranks 138 out of 174 countries on the UNDP Human Development Index (1998). Access to education and health is very limited: more than 55 per cent of the total adult population is illiterate with the adult female literacy rate estimated to be 20.9 per cent; and 89 million people lack access to basic health facilities. During the period 1980-1998, very little investment was made in the social sector. It is estimated that Government expenditure in the social sector has averaged only 3.0 per cent of the gross national product.

9. Pakistan has ratified the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). However, women are underrepresented in all decision-making bodies.  

For example, in 1994 only 1.6 per cent of the Members of Parliament were women. Gender disparities persist and incidents of gender violence are on the rise.    

Previous UNFPA assistance

10. The fifth UNFPA country programme for Pakistan was approved in 1993 for a five-year period in the amount of $30 million, of which $20 million was to be committed from UNFPA regular resources and $10 million from a combination of regular and other resources, including multi-bilateral resources. In order to complete all the planned programme activities, the programme was extended in 1998 until the end of 1999, with additional resources in the amount of $7 million from UNFPA regular resources. Against an overall approved programme level of $37 million, the total estimated expenditures of the fifth country programme by the end of 1999 are likely to amount to $31.2 million, of which $28.7 million would be from regular resources.  

11. UNFPA support has contributed to enhancing the capacity of the Government and NGOs to deliver quality RH/FP services. Both access and coverage have increased, especially in the rural areas. UNFPA support for training activities and for two outreach schemes, the Lady Health Worker (LHW) and the Village Based Family Planning Worker (VBFPW), has been a key factor in improving the quality of and expanding access to RH/FP services. Specifically, the Fund’s support has focused on increasing the availability of contraceptives, training community health workers and service providers and improving contraceptive logistics management. With support from UNFPA, five NGOs, including the Family Planning Association of Pakistan, the Pakistan Voluntary Health and Nutrition Association, the All Pakistan Women’s Association, the Behbud Association and Marie Stopes International have trained health service providers and community workers and have provided RH/FP services in the areas of their operations.  

12. UNFPA support has also led to an increased awareness about population issues through focused information, education and communication (IEC) programmes. The Fund has provided support to the Population Education Programme of the Ministry of Education for the development and inclusion of family life education (FLE) materials in the curricula of the formal education sector at the primary level and for the development of training materials for teachers. More than 20,000 teachers have been trained on FLE topics. In addition, UNFPA support has helped to strengthen the technical capability of national institutions to undertake policy-oriented research, collect and analyse population data, and conduct the population census.  

13. The efforts of UNFPA and other partners working in the field of population and development were a key factor in the formulation of the National Population Policy which was announced by the Prime Minister on World Population Day in July 1998. The policy recognizes population as a cross- cutting issue for all sectors, including the NGO and private sectors. It aims at creating an enabling environment to achieve further mortality and fertility declines by promoting gender equity and equality through education programmes for women and men. The policy acknowledges the need to enhance the availability of a national package of reproductive health services together with improvements in the quality, range and utilization of those services.  

14. A number of lessons may be drawn from the fifth country programme. First, it has become evident that policies aimed at bringing about a change of social behaviour in such areas as fertility and family formation patterns can only achieve their objectives to the extent that they are holistic in design and gender-sensitive and equip people with tools to make choices. Second, at the policy level a clear division of roles and responsibilities between the different Government institutions should be made in accordance with their respective mandates and comparative advantages. Third, UNFPA should increasingly support a range of national partners beyond the Ministry of Population Welfare (MOPW) in order to ensure wide coverage and expanded access to quality RH/FP services. Fourth, UNFPA should increase its support to civil society organizations through a genuine community-based participatory process since sociocultural barriers, especially those affecting reproductive health and rights, can be overcome only when communities take ownership of programmes and promote them actively. Finally, further support should be provided to the provincial departments to strengthen their managerial, delivery, monitoring and data analysis capacities. At the same time, the policy, coordination and advocacy roles of the federal departments should be strengthened.  

Other external assistance  

15. A number of donors are supporting population and development activities in Pakistan. The World Bank, the Asian Development Bank, the European Commission, the United Kingdom’s Department for International Development (DFID) and the Government of the Netherlands support the second phase of the Social Action Programme (SAP/PII). The European Commission funds the European Commission/UNFPA Initiative on Adolescent Reproductive Health in Asia through four reproductive health projects being executed by European and Pakistani NGOs. The Asian Development Bank supports a population project and has just approved a women’s health project. The World Bank supports a population welfare project to expand RH/FP services and improve their quality. DFID is engaged in policy dialogue with the Government on institutional reforms in the area of population and reproductive health. In 1998, DFID provided contraceptives to the LHW programme. It also provides support to private sector agencies and NGOs to deliver RH/FP services. In addition, the Japan International Cooperation Agency (JICA), the Canadian International Development Agency (CIDA), the Australian Agency for International Development (AusAID), and the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) support population and reproductive health activities.  

16. In 1997, UNFPA took the lead in facilitating the establishment of a Donors Task Force on Reproductive Health and Population and continues to act as its secretariat. The Task Force includes representatives from the bilateral and multilateral donors mentioned in the previous paragraph. The Task Force has proved instrumental for systematic donor collaboration and coordination. In addition to its key role in the Task Force, UNFPA actively participates in and supports activities with United Nations Development Group (UNDG) partners in a number of areas. With regard to HIV/AIDS prevention, UNFPA works closely with the Joint United Nations Programme on HIV/AIDS (UNAIDS) of which it is a co-sponsor. UNFPA supports the SAP and has become a regular participant in the Government/Multi-Donor Support Unit, which is funded by SAP/PII. The Fund also supports the Government in its collaboration with international NGOs such as The Population Council, the Asia Foundation, AVSC International, Pathfinder International and Population Communications International.  

Proposed programme  

17. The overall goal of the proposed programme has been noted in paragraph 4. UNFPA assistance would be delivered through three subprogrammes focusing on reproductive health; population and development strategies; and advocacy. Under the proposed programme, UNFPA would continue its efforts to bring about a functional integration of the MOPW and the Ministry of Health (MOH) to create greater synergy between the two parallel systems and to enable a sharper focus on reproductive health services. Building national capacity for RH/FP service delivery would be a central concern of the proposed programme. The three subprogrammes are described below.  

18. Reproductive health subprogramme. The purpose of this subprogramme is to contribute to: (a) improving the quality and increasing the utilization of reproductive health information and services, including family planning, particularly in the rural areas and among younger couples; (b) enhancing institutional capacity to manage and implement reproductive health programmes, including improving programme accountability; and (c) increasing the involvement of men in matters pertaining to reproductive health and responsible parenthood.  

19. The first expected output of the subprogramme would be improved access to quality RH/FP services for women, men and adolescents. Activities undertaken to achieve this output would include increasing the number of trained community-based workers (LHWs and VBFPWs) and community- based centres such as basic health units and family welfare centres; and improving the referral system for emergency obstetric care. Funds will also be used to improve the medical facilities and equipment of the above-mentioned centres to ensure quality services. Another output would be enhanced planning and management capacity in the area of reproductive health. To achieve this, support would be provided to increase the number of trained reproductive health programme and service managers at the national, provincial and district levels. Periodic learning opportunities would be provided to upgrade their planning and management skills. Support would also be provided for the procurement of equipment, including computers, to help improve management efficiency and effectiveness, as well as to ensure cost-effective reporting systems. The Fund would also continue support to the Technical Support Unit (TSU), which has shown great potential for providing expert advisory services to Government and NGOs in the areas of RH/FP, management, IEC, management information systems and advocacy.  

20. A third output would be improved access to reproductive health information and counselling for youth. Towards this end, support would be provided to increase, in both the public and private sectors, the number of health service providers sensitized to the specific reproductive health needs of adolescents and young couples. In addition, the number of youth counsellors would be increased in such institutions as the Pakistan Red Crescent Society.  

21. The fourth output would be a behavioural change leading to more responsible family formation patterns among young men and women in the country. This output is expected to result from, inter alia, the following activities: increasing the number of trained service providers/extension workers in inter-personal communication and counselling; increasing the involvement of men in RH/FP and responsible parenthood matters; and expanding the FLE curriculum to cover intermediate and college levels. A fifth output would be an improved management information system for the management, supply and distribution of a balanced mix of modern contraceptives. In addition to funding for the provision of contraceptive supplies, support would be provided to establish procedures at federal and provincial levels to ensure a functional integration between MOPW and MOH for reproductive health service delivery.  

22. A total amount of $26.9 million would be allocated to the reproductive health subprogramme, of which $6 million would be sought from multi-bilateral and/or other sources. Possibilities for multi-bilateral assistance are being explored with a number of bilateral donors, including Australia, Canada, Japan and the Netherlands. Should the multi-bilateral resources become available, the reproductive health service components of the programme would be expanded.

23. Population and development strategies subprogramme. Based on the CPA findings and taking into account the objectives of the Ninth Five-Year Plan, the purposes of the population and development sub-programme would be to strengthen the national capacity in population studies and research, including in the area of gender, and the capacity of the Census Commission to collect, analyse and utilize gender-disaggregated data in development policies and plans.

24. The three expected outputs of this subprogramme would be: (a) a wide consensus on and support for the National Population Policy, in particular for its reproductive health and gender equity and equality goals; (b) improved capacity of the Census Commission to carry out an in-depth analysis of the census and to interest district planners in using the census analysis in their development planning; and (c) strengthened research and analysis capacity at selected population and development institutions to enable the provision of sound advice for policy decisions.

25. To achieve these outputs, the subprogramme would support the following activities: disseminating the recently approved National Population Policy and facilitating dialogue with all stakeholders, especially line ministries, provincial authorities and NGOs on their role in its implementation; strengthening the institutional, technical and analytical capacity of the Census Commission to carry out an in-depth analysis of the 1998 Census, produce district profiles and ensure their utilization by district leaders as a strategic planning tool in development planning; and strengthening training and the applied research capacity of selected institutions such as the National Institute of Population Studies and the Pakistan Institute of Development Economics.  

26. Support would be provided to enable institutions to carry out research on key population, reproductive health and gender equality issues and to develop pertinent indicators for programme monitoring and evaluation of the national population programme. For example, support would be provided for research on sociocultural change and factors influencing gender inequality in the country. Research findings would be used to improve the management as well as the quality of RH/FP services. In addition to ongoing South-South collaboration, efforts will be undertaken to support South-South initiatives in such areas as management capacity building, quality of care and advocacy.

27. A total of $5.0 million would be allocated for the population and development strategies subprogramme, of which $1.0 million would be sought from multi-bilateral and/or other sources. UNFPA is exploring the possibility for multi-bilateral resources with donor countries who have expressed an interest in this sector, including Australia and Canada.  

28. Advocacy subprogramme. The CPA underscored the need to rally the support of influential leaders for reproductive health and reproductive rights with a special focus on gender equity and equality. In particular, there is a need to generate strong support for population programmes among community and traditional leaders. Over the last few years, support has increased for family planning programmes as they have come to be recognized as strategic for more balanced growth and a higher development dividend. However, while support for family planning has been on the rise, other key issues underscored by the ICPD Programme of Action have not been fully addressed. These issues include reproductive health and reproductive rights; gender equity and equality; male involvement and shared responsibility in all matters pertaining to reproductive health, including HIV/AIDS; and the exposure of young people to behavioural risks.  

29. Given that context, the advocacy subprogramme would seek to: mobilize active support from community and religious leaders, policy makers and the media for promoting reproductive health information and services, girls’ education and the elimination of laws and practices that discriminate against women; and generate a better understanding among legislators, policy makers and other leaders of the importance of population, gender and development issues.  

30. The expected outputs of this subprogramme would be: wider national and local support for reproductive health; increased information on reproductive health for young people with particular attention to gender considerations; increased capacity of media practitioners to advocate for population issues; improved understanding of population and development issues among planners so as to facilitate the integration of RH/FP issues in district development planning; and a sustained national debate on the importance of education for the girl child.

31. Activities that would be supported under this subprogramme would include workshops and seminars to sensitize and inform religious and political leaders, including parliamentarians, as well as other opinion leaders and media practitioners. This component, which is expected to help bring about an enabling environment for social change, would build upon current initiatives with parliamentarians and religious leaders. In addition, UNFPA, for the first time, would explore advocacy avenues with district leaders, especially the 121 district Deputy Commissioners who are very influential with regard to allocation of resources, development planning and visibility of issues. Furthermore, given the need to decrease gender inequality in Pakistan, the subprogramme would provide support to the Ministry of Women’s Development in its efforts to implement the post-Beijing National Plan of Action in collaboration with other United Nations agencies and bilateral donors. The amount of $2.5 million from UNFPA regular resources would be allocated to the advocacy subprogramme.

Programme implementation, coordination, monitoring and evaluation  

32. The MOPW has traditionally been the primary ministry in charge of the population programme in Pakistan. Until recently, its mandate and scope of work had placed strong emphasis on narrowly defined family planning and target-driven programmes. However, as Pakistan progressed to a broader reproductive health approach, a number of ministries such as those of Education, Labour and Manpower, Women’s Development, and Health became interested partners, eager to be involved in the implementation of the ICPD Programme of Action. The proposed programme would be implemented by MOPW and MOH as well as other line ministries. As the institutional capacity for the implementation of population activities needs to be improved, the recently established Technical Support Unit would be used to strengthen the organizational development of government institutions, especially MOPW and MOH.  

33. Under the proposed programme, support would be provided to Government departments involved in RH/FP at federal and provincial levels. Priority would be given to national execution and to strengthening the capacity of national institutions to design, implement, monitor and evaluate programmes. Using a transparent and accountable mechanism, UNFPA would also channel support to NGOs at federal and provincial levels. National professional project personnel (NPPP) have proved to be a valuable resource for strengthening the implementation and monitoring capacity of government institutions. It is foreseen that NPPP may be recruited under the proposed programme.  

34. Special efforts would be made to achieve more effective functional coordination of donor inputs and support. UNFPA would continue to capitalize on the Donors Task Force, which has proved effective in avoiding duplication in delivering population and development assistance.  

35. Qualitative and quantitative indicators as delineated in the logical framework of the proposed programme would be used in the monitoring and evaluation of the programme activities. In keeping with UNFPA guidelines and procedures, annual programme reviews, a mid-term programme review and an end-of-programme evaluation would be conducted to assess the progress achieved.  

36. The UNFPA country office is composed of a Representative, a Deputy Representative, two Assistant Representatives and General Service staff. Currently, the office also has the services of one junior professional officer and one United Nations volunteer.  

37. An amount of $0.6 million from UNFPA regular resources would be allocated for programme coordination and assistance.

Recommendation  

38. The Executive Director recommends that the Executive Board approve the proposed programme of assistance to the Government of Pakistan, as presented above, in the amount of $35 million for the period of 2000-2003, of which $28 million would be programmed from the Fund’s regular resources, to the extent such resources are available. UNFPA would seek the balance of $7.0 million from multi-bilateral and/or other, including regular, resources to the extent possible, consistent with Executive Board decision 96/15 on the allocation of UNFPA resources.