Pakistan - Counting What Counts: Tracking Access to Emergency Contraception
Publication date: 2013
April 2013 EC is widely available in the public, commercial, and social marketing sectors. Policies support the availability of EC but caution against its use as a regular family planning method. Community health workers have been trained to distribute EC and there are plans to scale up such programming. ABOUT PAKISTAN Pakistan is the sixth most populous country in the world, with an estimated population of 193,238,868, of which 92,545,823 are women. It is a poor, developing nation that struggles with political and economic instability. The country is largely rural, with 64% of the population residing in rural areas and 36% in urban areas. The literacy rate is 54.9% for the general population, with female literacy at 40.3%.1 Sixty-one percent of the population lives under 2 USD per day.2 CONTRACEPTIVE KNOWLEDGE AND USE POLICIES Essential Drug List: Levonorgestrel in the proper dose for EC is not included in the 2007 EDL.4 National Norms and Guidelines: There is a section on emergency contraception in the Manual of National Standards for Family Planning Services,5 a document developed by the Family Advancement for Life • Total fertility rate: 4.1 children per woman (4.5 Rural, 3.3 Urban) • Unmet need for contraception (among ever married women): 24.9% • Knowledge of contraception (among ever married women): 95.7% • Current contraceptive modern method use (among ever married women): 21.7% (29.9% urban, 17.7% rural) • Knowledge of EC (among ever married women): 17.8% Source: Demographic and Health Surveys, Pakistan 2006-07.3 and Health (FALAH) project. The manual includes an introduction to EC, a short section on policy, effectiveness, when EC should be used, counseling, and follow-up. It contains stipulations that EC should only be used by women in cases of emergency; should be dispensed only by skilled service providers along with counseling services; and should not be used as a regular family planning method. Prescription Status: Clinic staff, including doctors, nurses, and in select districts, female community health workers (officially termed Lady Health Workers or LHWs) are able to dispense EC.6 It is also widely available in pharmacies and medical shops for purchase.7 Post-rape care: The 2009 Manual of National Standards for Family Planning Services6 states that women, especially young women, in conflict situations are vulnerable to sexual assault. The manual acknowledges a lack of available EC services and emphasizes the importance of increasing EC provision. It also states that EC should be implemented in the same manner as other health interventions – in accordance with cultural values and national protocols; and that EC is in line with the national family planning policy.5 PRODUCT AVAILABLITY Registered Products: The ICEC database lists two levonorgestrel-only EC products registered in Pakistan,8 both locally manufactured. Postinor appears to be available in Pakistan but, according to the manufacturer, is not registered in Pakistan. Locally manufactured products: EC products are manufactured in Pakistan. PAKISTAN Pa kis ta n COUNTING WHAT COUNTS: TRACKING ACCESS TO EMERGENCY CONTRACEPTION Pa kis ta n 2 Poor quality or counterfeit EC products: No information is available at this time about issues of poor quality or counterfeit EC products in Pakistan. WHERE WOMEN CAN ACCESS EC EC in the commercial sector: EC is available for behind-the-counter purchase at pharmacies and medicine shops. Emkit, a two-pill regimen, is available for Rs. 15 (approximately 0.16 USD). EC in the public sector: In 2007, the Frontiers in Reproductive Health (FRONTIERS) program worked with the FALAH project and the Government of Pakistan to introduce emergency contraceptive pills (ECPs). A recommendation emerged from a national seminar that the availability of ECPs could be enhanced if made available through national health system outlets, including via community-based LHWs. In 2010, the FALAH project implemented a training program for LHWs to provide ECPs. The training program occurred in four districts, one in each of the four provinces of Pakistan from February–June 2010. An evaluation of the introduction of ECPs through LHWs was conducted and the report, published in January 2012, concluded that scale-up of the program across the country should occur.6 EC in the NGO, social marketing, and social franchising sectors: Greenstar Social Marketing, an affiliate of Population Services International (PSI), currently implements EC programs in Pakistan. In 2003, Greenstar introduced the first socially marketed ECP in the country,9 and in 2011, 1,387,152 packets of EC were sold.10 Greenstar operates approximately 8,000 clinics and pharmacies that offer EC in 4 states, with a plan to expand into more rural areas. The clinics are staffed by physicians, Family Welfare Workers (government employees staffed at health centers), LHWs, and midwives.11 In 2008, Population Council reported that Greenstar had 76% of the market share of EC products and that the Ministry of Population Welfare had the rest.8 Community-based distribution of ECPs: Under the FALAH project, trainings on EC were provided to 2,687 LHWs in four districts; in these four districts, EC products were also provided for distribution by LHWs.6 PROVIDERS A 200912 study conducted at a teaching hospital in Karachi assessed provider knowledge of and attitudes toward EC. Results showed that while a majority of participants (71%) were familiar with EC, there were large gaps in their knowledge. Only 33% of respondents answered that EC was not an abortifacient, while 42% were unsure. Forty percent of the physicians had prescribed EC before. Providers reported barriers to prescribing EC including beliefs that it would promote promiscuity (31%), religious or ethical opposition (27%), sense of liability when prescribing (44%), and concerns about side effects or birth defects (44%). The research found that while the majority (60%) of medical practitioners had favorable attitudes toward EC, there was acknowledgement within the health community that more information must be provided. MEDIA COVERAGE OF EC There have been some articles in the news about EC, including a March 2010 article titled “Emergency Contraception more popular, but myths abound,” through InterPress Service13 and a January 2010 Daily Times article, “The morning- after pill that works 5 days after sex.”14 DONOR SUPPORT RHInterchange indicates that UNFPA purchased a total of 240,000 packets of EC for Pakistan from 2009 to 2010.15 Other donor programs include: KFW, German Development Bank, USAID, the Packard Foundation, and The Global Fund (through Greenstar programs), as well as Marie Stopes Society, a subsidiary of Marie Stopes International.11 3 Pa kis ta n REFERENCES 1 CIA World Factbook. Retrieved April 4, 2013 from https://www.cia.gov/library/publications/the-world- factbook/geos/pk.html. 2 Population Reference Bureau, 2012. Retrieved April 4, 2013 from http://www.prb.org/DataFinder/Geography/ Data.aspx?loc=386. 3 Demographic and Health Survey 2006-07. Pakistan. National Institute of Population Studies (NIPS) [Pakistan] and Macro International Inc, 2008. 4 National Essential Medicines of List of Pakistan. Ministry of Health, Government of Pakistan, Islamabad, 2007. 5 Manual of National Standards for Family Services. FALAH project for Ministry of Population Welfare, Government of Pakistan, December 2009. 6 Mahmood, A. and Nasir, Y.B. Introduction of Emergency Contraceptive Pills (ECPs) through Lady Health Workers (LHWs) Program in Pakistan. Population Council, January 2012. 7 FAQs on Contraceptive Methods and Use. Retrieved April 4, 2013 from http://www.falah.org.pk/. 8 ICEC EC Status and Availability Database. Retrieved April 4, 2013 from http://www.cecinfo.org/country-by- country-information/status-availability-database/countries/ pakistan/. 9 Greenstar Social Marketing. Accessed April 4, 2013 from http://www.greenstar.org.pk/who-we-are.htm. 10 DKT 2011 Contraceptive Social Marketing Statistics. DKT International, 2012. (http://www.dktinternational.org/ wp-content/uploads/2011/11/2011-Statistical-Mktg- Rpt2.pdf) 11 Schlein, K. and Montagu, D. Clinical Social Franchising Compendium: An Annual Survey of Programs, 2012. San Francisco: The Global Health Group, Global Health Sciences, University of California, San Francisco, 2012. 12 Abdulghani, H.M., Karim, S.I., Irfan, F. Emergency contraception: knowledge and attitudes of family planning physicians of a teaching hospital, Karachi, Pakistan. Journal Health Population and Nutrition 2009; 27(3): 339-334. 13 Zofreen, E. PAKISTAN: Emergency contraception more popular, but myths abound. IPS-InterPress Service News Agency, March 2, 2010. (http://www.ipsnews.net/2010/03/ pakistan-emergency-contraception-more-popular-but- myths-abound/) 14 The morning-after pill that works for 5 days after sex. Daily Times Article, January 30, 2010. (http://www.dailytimes.com.pk/default asp?page=2010%5 C01%5C30%5Cstory_30-1-2010_pg9_8) 15 RHInterchange. Retrieved April 4, 2013 from http://rhi.rhsupplies.org/rhi/quantitysummary.do. This fact sheet has been prepared by the International Consortium for Emergency Contraception and represents the best information we have been able to gather. We welcome your input for future revisions. Please contact us at firstname.lastname@example.org. Visit our website at www.emergencycontraception.org for more information on EC.