Bill & Melinda Gates Foundation

Pakistan: A Tough but Vital Place to Do Family Planning

August 06, 2015

A couple of years ago, I was traveling in the rural areas of Sindh Province in Pakistan and met a woman who had six children. Her resources were so meager that she had to feed her children in shifts — three on one day, and the other three the next day. It was heart-breaking to see. But it made me more convinced than ever of the importance of the work my colleagues and I are doing to provide Pakistani couples with options for healthy spacing and timing of births.

I live and promote family planning in Pakistan, where only 26% of married women use a modern method of family planning, dramatically lower than the 66% who use modern methods in my native Mexico. That’s lower than all our neighboring countries, except Afghanistan. Yet 20% of married women say they want contraception but cannot access it.

The Government of Pakistan has pledged to increase the contraceptive prevalence rate (CPR) for modern methods from the 26% recorded in the 2012-13 Demographic and Health Survey to 55% by 2020. That would double the CPR in only eight years.

My job is to help the government reach that goal, but family planning is a tough issue in Pakistan. It is difficult to discuss contraception openly in Pakistani society because of traditional values and the patriarchal nature of society. Women dare not discuss family planning even in their own homes. Obstacles to family planning include pressure to have many children and at least one male child. The pressure can come from the husband, the mother-in-law, other family members or society at large.

We even face these traditional values inside our own organization, DKT Pakistan, which is a family planning organization. Sometimes we hire new employees for the sales team who are shy about contraception, and we have to spend time developing their confidence. Some leave the job within a few months after deciding they are not comfortable selling contraceptives. So we have to find a new person and give them training and confidence-building all over again.

Despite the many obstacles, we are working hard to change norms around family planning, especially with men. In 2015, we are working with men to help them understand the benefits of family planning. For example, DKT sponsors tea parties for men and women to relax and converse about long-acting reversible contraceptives. We also hold mobile video shows in rural areas, with separate shows for women and men.

The mission of DKT Pakistan, founded in 2012, is to provide couples with affordable and safe options for family planning and HIV prevention through social marketing and social franchising. We apply a relentless focus on the poor, the rural and the hard-to-reach.

DKT Pakistan, like the other 20 DKT International programs around the world, tries to push cultural boundaries, without violating them, in order to make the greatest impact possible (see our best TV spots from around the world). Sometimes we ruffle feathers.

In 2013, we aired a controversial TV spot featuring the provocative Pakistani model Mathira playing a newlywed trying to please her husband in the bedroom. It aired 10 days before being banned by censors. The controversy revealed Pakistanis’ squeamishness over sex. The spot has now been seen millions of times on YouTube and helped increase DKT’s sales of Josh condoms.

Our other TV spots have also attempted to increase demand for our products in creative and compelling ways.

DKT Pakistan has built up a social franchising network of 800 midwife-owned and operated Dhanak clinics in a little less than three years (Dhanak means rainbow in Urdu). We aim to have 1,200 clinics by the end of 2015. The clinics operate in all parts of Pakistan — from the deserts of Sindh in the south to the snow-capped Himalayan peaks of the north. Some of these clinics are as far as an eight-hour drive from the nearest town.

We are going to remote and rural areas with difficult access, where many other organizations do not. For example, we are opening clinics in the provinces of Khyber Pakhtunkhwa and Baluchistan, areas of extreme poverty.

Although the 800 Dhanak clinics are in very different regions and cultural settings, they have a few things in common:

  • They are located mainly in rural areas, where 65% of Pakistanis live.

  • They share franchising principles, such as standard appearance, signage, advertising, etc.

  • They carry out regular quality assurance to ensure that all clinics meet and maintain high standards of quality.

  • They offer training and refresher training to ensure that their clinical staffs have the skills they need to provide optimal health care.

  • They provide a full line of reproductive health services and products, most of which are offered through DKT Pakistan’s parallel social marketing program.

Since the Dhanak clinics are usually owned and operated by women, the clinics also empower women and provide a model of entrepreneurial self-sufficiency.

DKT Pakistan has just joined the work led by Aman Health Care Services under the SUKH Initiative with support from the Bill & Melinda Gates Foundation and the David and Lucile Packard Foundation with the goal of increasing modern contraceptive use by 15% among married women in selected, low-income communities of Karachi.

As its contribution to the SUKH Initiative, DKT will identify and franchise 80 private sector clinics as Dhanak clinics in low-income urban areas and promote family planning in the private sector. Due to political and ethnic violence, many health providers have abandoned their facilities in the selected areas so these clinics will contribute a great deal to their communities. The first 35 clinics are expected to be operational in 2015.

In Pakistan, there are many obstacles that stand in the way of greater acceptance and use of family planning. But Pakistani women want it, and we are determined to use the vibrancy of the private sector to offer it to them.



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