International Development Committee inquiry: Aid to Pakistan
Written evidence from MSI Reproductive Choices
About MSI Reproductive Choices
MSI Reproductive Choices (MSI) is one of the world’s largest providers of sexual and reproductive health services, and a global advocate for gender equality and reproductive choice. We work in 37 countries as a key partner to ministries of health. By the end of 2020, over 37 million women globally were using a form of contraception supplied by MSI.
About Marie Stopes Society in Pakistan
Registered in 1990, Marie Stopes Society (MSS) in Pakistan is a locally registered implementing partner of MSI Reproductive Choices. MSS is a locally registered NGO which provides access to quality reproductive health services and information. MSS works closely with the government and other service providers to deliver national sexual and reproductive health policies, and to train private and public providers to improve their quality and health systems, sharing expertise and expanding reach.
1. Sexual and reproductive health in Pakistan
1.1 There is a critical need for the UK Government to maintain its commitment to aid in Pakistan. Major development challenges include education, literacy, healthcare, infant mortality, and the impact of climate change, such as natural disasters. Underpinning many of these development challenges is the need to increase access to sexual and reproductive health and rights (SRHR).
1.2 There is a significant unmet for family planning need in Pakistan. Despite the Pakistani Government becoming a signatory to the Family Planning 2020 pledge, nearly one in five women in Pakistan still has an unmet family planning need. In 2018, only 25% of women in Pakistan were using a modern method of contraception.
1.3 There are over 80 maternal deaths every day (an estimated 30,000 each year) from preventable complications during pregnancy. Accurate data around abortion is difficult to collect; the soundest measure is hospital admissions due to unsafe abortion. Estimates suggest that around 197,000 women are treated in public and private teaching hospitals for complications of induced abortion each year.
1.4 In addition to the impact this has on the women and families affected, these incidents increase pressure on health services which are already under-resourced. According to a study published in the Journal of the Pakistan Medical Association, pregnancy and abortion complications “can exert a significant financial burden on the already fragile health care systems of developing countries and hence reduce their capacity to provide other much needed services.”
2. The role of development and MSS
2.1 Since 2012, MSS has worked in partnership with the former Department for International Development (DFID), which has continued successfully throughout the process of amalgamating DFID into the Foreign and Commonwealth and Development Office (FCDO).
2.2 MSS delivers family planning, post-partum, post-abortion care and through various service delivery channels including clinics, social franchisees, mobile vans, and online services. The social franchise network increases the number of family planning providers, especially in rural areas, targets the poorest with family planning vouchers to mitigate financial access barriers, and supports women with information, services and care that is rights-based, non-judgmental and accessible.
2.3 MSS is currently implementing the five-year FCDO-funded projected ‘Delivering Accelerated Family Planning in Pakistan’ (DAFPAK). It runs from December 2017 to March 2022. This project builds on the successes and lessons learned from previous FCDO sexual and reproductive health projects in Pakistan, with implementation of interventions for increased sustainability and drive for Value for Money (VfM).
2.4 DAFPAK employs intensive targeting to concentrate resources on the regions, populations and service delivery mechanisms that are facing the greatest challenges today. To ensure that project investments leave no one behind and make the most efficient use of available resources, MSS has employed thorough geographic targeting in the selection of the geographic regions. MSS has selected the areas with the poorest maternal and child health outcomes, and areas with the highest unmet need for family planning.
2.5 MSS operates innovations and pilot projects for expanding access to family planning and reproductive health services. This is achieved through expanding the services offered at three MS Pakistan centres with the highest potential for return-on-investment, supported by a health insurance pilot, through establishing retail pharmacy outlets which increase access to essential medicines in high demand areas, and through a family planning and reproductive health Training Resource Centre in Karachi, Sindh.
2.6 The DAFPAK project design is built on a fundamental foundation of equitable access, regardless financial resources, age, prior knowledge of reproductive health and rights or geographic location.
2.7 As of March 2021, DAFPAK has served 829, 871 clients, with over 314,000 services provided to women in rural areas, and over 289,000 impoverished women receiving vouchers for services.
CYP (Couple of Years Protection)
Total Clients Served
FP (Family Planning) Clients Served
Non-FP (Family Planning) Clients served
2.8 “Helping the world’s most vulnerable” remains a stated priority for FCDO.
2.9 In Pakistan, one in eleven children dies before reaching the age of five, with pre-term birth complications, birth asphyxia or trauma being one common cause. A Guttmacher Institute study found that if all births were spaced by at least two years, the number of deaths among children under five would decline by 13%, 25% if there were a three-year gap. Allowing women to control when and if they become pregnant means that families can plan for having children at the safest, most financially appropriate time for their needs. Access to reproductive health services is strongly recommended as a key part of improving child health and mortality rates.
2.10 Similarly, gender equality cannot be achieved without access to fundamental reproductive healthcare. The UK Government has pledged to a number of commitments on gender equality, which include getting six million more girls into education. The Danish Institute for Human Rights found that an adolescent girl without formal education is more than four times as likely to become pregnant than an adolescent girl with secondary education.
2.11 Access to reproductive services is therefore critical for women’s educational and economic equality, independence, and equal participation in society. To maintain its own pledges, the government must continue to invest in the essential partnership that allows MSS to deliver this programme.
2.12 “Promoting global prosperity” is an FCDO priority. On making the global pledge to support six million more girls into education, the UK Government rightly identified girls’ education as “a key driver determining a country’s economic success” because “a child whose mother can read is 50% more likely to live past the age of five and twice as likely to attend school herself, one additional school year can increase a woman’s earnings by 20%, and $28 trillion would be added to global GDP if women had the same role in the labour market as men.”
2.13 Demographic trends have a significant impact on economic development, with planned reproduction ensuring a sustainable ratio of working adults to dependents. Access to reproductive healthcare is not only essential for meeting stated equality targets; it is also vital for economic sustainability. To support Pakistan’s economic development in line with the goal of “promoting global prosperity,” levels in sexual and reproductive health must be sustained.
3. Our recommendations
3.1 Recognition that sexual and reproductive health is essential
3.1.1 We would welcome the re-assertion of a commitment to prioritising sexual and reproductive health and rights within development investments. The UK Government will not be able to meet its commitments on key priorities without technical support and strong action from donors to support MSS’s programme.
3.1.2 Pakistan is especially vulnerable to political tensions, poverty, natural disasters, and the impact of climate change. Sexual and reproductive healthcare needs should not be seen as secondary to these development challenges. On the contrary, during crisis and/or conflict, there are often higher rates of maternal mortality, neonatal mortality, infant mortality, and sexual violence. Sexual and reproductive healthcare needs should be viewed as a core part of supporting refugees and internally displaced people.
3.1.3 There is an opportunity for FCDO to play a stronger role in the successful delivery of this work, especially as Pakistan is now a signatory to the Family Planning 2020 Pledge but progress is still slow.
3.1.4 We strongly recommend that women’s organisations, NGOs and SRHR experts continue to be consulted about any changes to Pakistan’s aid programme. We also encourage the UK Government to encourage greater openness from Pakistan’s government on reproductive rights, including safe abortion.
3.2 Bolder approaches to facilitating independent service provision
3.2.2 The majority of sexual and reproductive healthcare is provided through the state. Yet there is huge potential to capitalise on the extensive independent sector network of midwives and Lady Health Visitors (LHVs). This would especially improve the provision of Long-Acting Reversible Contraception (LARC) in rural and more deprived areas. Independent service providers have expertise, skills, resources, and a record of efficient delivery. We would like to see bolder approaches to facilitating a great mix of provision, so that independent providers can innovate together with the communities we are serving to establish trusted, compassionate services where they are needed the most.
3.2.3 FCDO should continue to actively promote and support the integration of expert NGO and community-based service providers into public health systems to strengthen health systems.
3.3 Technical support and pilot studies to expand task-sharing
3.3.1 Task-sharing is about using resources in the most efficient, effective way possible. It involves a shift in how activity is allocated so that, where safe to do so, tasks are carried out by a health worker with fewer qualifications.
3.3.2 In Pakistan, there are workforce challenges, particularly for sexual and reproductive health services. Task-sharing is proven to boost capacity and maximise the use of resources, ultimately improving access to services as well as using resources efficiently.
3.3.3 We recommend strong support for allowing trained midwives and nurses to provide contraceptives, ideally in the form of technical support.
4.1 In order to meet its stated goals, the UK Government must recognise that sexual and reproductive health and rights are essential in Pakistan, where poverty, gender inequality, and internal displacement is widespread. Any changes to aid in Pakistan should be done in meaningful consultation with women’s groups and NGOs.
4.2 To address challenges with resources and access to sexual and reproductive health services in Pakistan, there must be support for the role that independent service providers can play. There should be a commitment to encourage task-sharing in service provision, which evidence has shown can improve access while delivering services efficiently.
4.3 With the UK Government due to host the G7 this year, the spotlight will be on our approach to development. It is essential that any reforms made to Pakistan’s aid programmes are seen as credible among those in the international development sector, among the citizens of Pakistan themselves, and among the rest of the world.
 Hackett K, Henry E, Hussain I, et al. Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study, BMJ Open 2020;10: e039835. doi: 10.1136/bmjopen-2020-039835
 Sathar ZA, Singh S, Fikree FF. Estimating the incidence of abortion in Pakistan. Study Family Planning, 2007; 38: 11-22.
 Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan, Journal of the Pakistan Medical Association, Nusrat Shah, Nazli Hossain, Mukhtiar Noonari, Nusrat Hassan Khan.
 Family Planning Can Reduce High Infant Mortality Levels | Guttmacher Institute
 Reproductive Rights are Human Rights: A Handbook for National Human Rights Institutions, the Danish Institute for Human Rights
 PM steps up UK effort to get every girl in the world into school - GOV.UK (www.gov.uk)