A group of pregnant women are discussing their health issues with one another at Family Health Clinic, Johar Town Lahore. Shumaila, in her late 20s, is pregnant for the third time. She is unhappy. Razia, who is in her 30s, is expecting her fifth child. She looks depressed. Her husband wants another son.

Asked if a lady health worker (LHW) or a family welfare worker (FWW) has ever contacted them, supplied contraceptives or raised awareness about how to delay pregnancy, Shumaila says she is not aware of the services. "No one has ever reached out to me, except my paternal family members who have asked me to contact a specialist in family health. That’s why I am here."

Razia tells TNS that her in-laws reject family planning. So does her husband. They want more boys in the family. "We face serious financial problems. It frequently becomes very difficult to meet family’s daily expenses but my husband believes no one will die of hunger if we have more boys."

The National Programme for Family Planning and Primary Healthcare, also known as Lady Health Workers (LHW) Programme, was launched in 1994 to reach out to women like Razia and Shumaila and their families.

The programme aims at creating awareness about family planning and about various contraceptives. There are around 48,000 LHWs, mostly offering their services in rural areas.

Family Welfare Centres (FWCs) operate under the provincial Population Welfare Department. These centres are given targets for contraceptive prevalence, increasing the area of family planning, and improving mother and child health statistics. FWCs were to be established at each union council to cater to 5,000 people each through skilled workforce. The current number is 2,100, way short of 3,454 union councils across the Punjab.

The sanctioned staff for an FWC includes a Family Welfare Worker (the in-charge), male and female Family Welfare Assistants (responsible for field visits and registration of beneficiaries), a female helper and guard.

"At present, LHWs appear to be the most substantial constituent of the family planning services," says Sarfraz Kazmi, the Lahore Region director of the Family Planning Association of Pakistan (FPAP). "Their role is significant in preventive and primary care and in delivering some of the basic curative care in their communities as well as providing a link to emergency and referral care."

Lady health workers are not happy with their work load. Rukhsana Anwar, president Lady Health Workers’ Association tells TNS that 1500 persons or at least 150 houses are covered by one leady health worker. "The government has asked every worker to ensure administration of 60 deliveries per month at their Basic Health Unit and treatment of two tuberculosis patients from the area allocated to her," she says, adding, "This goes beyond our job description. In addition, we are asked to work in various other programmes, such as polio vaccination campaigns and dengue eradication operations."

She complains that the department sends them a show-cause notice whenever a worker cannot meet the target. The contraceptive boxes, she says, are not provided in time and when they are, many carry insufficient medicine.

Rukhsana says that the present number of LHWs is insufficient. "The last batch of workers was inducted in 2009, since then the department has been slow even filling vacant seats --due to retirement or death of a worker."

Dr Syed Mukhtar Hussain Shah, the project director of Integrated Reproductive, Maternal, Newborn & Child Health and Nutrition Programme (IRMNCH&NP), does not agree with Rukhsana. "Lady Health Workers Programme is part of the National Programme for Family Planning and Primary Healthcare. Therefore, deliver other services along with family planning services is part of their curriculum."

Shah says the purpose of reporting deliveries to the nearest BHU is to list and register pregnant women, provide them with better healthcare facilities and discourage midwifery. "The claim regarding non-availability of contraceptive boxes or insufficient medicine is not true."

Unfortunately, he adds, "forty percent of LHWs are involved in collecting ‘funds’ for their association and trying to blackmail the department rather than focusing on their actual duty."

Rukhsana says she is ready to prove her claims if required.

FWCs are another component of family planning services. To qualify for becoming assistants at the centres one has to obtain a two-year diploma after an FSc (pre-medical).

Sarfraz Kazmi, Lahore Region director of the FPAP believes FWCs and the workers are ineffective not only due to their inadequate number but also because they have been assigned the job of only registering eligible couples. "The actual job description also includes counseling and motivating couples to use contraceptives. These are the reasons behind Contraceptive Prevalence Rate (CPR) not increasing and the tension between workers and the authority."

CPR is the percentage of women of reproductive age (15 to 49) who are currently using, or whose sexual partner is currently using, at least one contraceptive method, regardless of the method used.

According to FPAP, CPR remained below 10 percent during the 1970s but increased significantly by 1990s to almost 28 percent. It stands at 35 percent today. It is estimated to be around 55 percent till 2020.

"Unfortunately, family planning is not part of our national policy. That’s why we have 2.2 million unsafe abortions per year, 170 mothers die per 100,000 live births, child mortality rate is 74.9 per 1000, and around 800 million kids are under nourished," says Kazmi.

In the socio-cultural milieu of Pakistan, family planning is not in the hands of females alone. The Village Based Family Planning Workers Scheme was introduced in 1992 in order to increase the coverage of Family Welfare Programme in rural areas and to improve its accessibility.

The scheme was expanded during the Eighth Five-Year Plan (1993-98) for the provision of family planning services in rural areas.

This programme  was launched as a pilot project in a few districts. Initially, it was planned to increase the number of male workers in a phased manner from 612 in 1998-1999 to 7012 in 2002-03, but the number could only be increased up to 787 by the end of 2000-2002. Today, according to Punjab government, only 6 Men Advisory Centres are operational.

Also read: Feet on the ground

Additionally, 129 family health clinics, 117 mobile units along with over 2000 social mobilisers and Family Planning Workers create awareness and provide family planning services. The Planning and Development Board realises that the current efforts for population planning are insufficient.

A former Executive Director of National Institute of Population Studies, Abdul Basit Khan, believes that as the world’s sixth most populous country, Pakistan faces the risk of natural disasters, a large and growing youth population, poverty and inequality, all of which pose significant challenge to delivering reproductive health services.

"The contraceptive prevalence rate has stagnated and the number of skilled-attendance at births is very low," says Khan. "Pakistan is committed to contribute 6.7 million additional users of modern contraception but in the absence of international donors for supply of contraceptives, especially for the rural areas, and given an insufficient work force; the future appears bleak."