4: Pakistan.

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1

INTRODUCTION TO THE COUNTRY'S SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) AND DEVELOPMENT CONTEXT

Human rights (1) are defined as the birth right of all human beings. The promotion and protection of human rights is the foremost responsibility of all governments. unfortunately, in Pakistan, political instability and long periods of dictatorships have impeded citizens from the full enjoyment of basic human rights. This is especially true of marginalised groups such as women. culturally and socially, women are considered to be inferior to men. Although the Pakistan constitution provides that every person shall be treated equally according to law, Pakistani women continue to suffer under the yoke of patriarchal structures, rigid orthodox norms, socio cultural customs and traditions.

In Pakistan, unemployment is high, as is social disparity. Poor socio-economic development in areas such as sanitation, potable water supply, nutrition and education and the inadequacy of health policies (and their implementation) has resulted in poor health indicators for men and women. Improvement in women's health has been further curtailed by social conservatism and inadequate outreach of primary and reproductive health care services--especially in rural areas.

1.1 Population policies and programmes: a brief history

Pakistan's population programme established in 1953 is perhaps one of the oldest in the Asian region. The first official population policy was introduced in the country's 3rd Five Year Plan (1965-70). The programme, which focused exclusively on motivating women to control their fertility, expanded considerably over the next decade. However, it failed to reduce fertility rates as it did not take into account the social reality that women possessed little or no say in making decisions about their own fertility.

The National Health Policy was formulated in 1990. It had provisions for trained birth attendants and expansion of mother and child health care (including antenatal care and natal care). It did not mention reproductive health and had a limited focus on EMoC. (2) The population policy of 1992 introduced new family welfare centers offering family planning and child health services and service centers in hospitals to provide sterilisation and other family planning services. A characteristic of the population programme was its lack of gender sensitivity: the focus on women for family planning and female sterilisation(in a culture where often the sole determinant of a woman's worth is her reproductive ability); and minimal male involvement (a problem that persists today).

In 1990, the Ministry of Population Welfare (MoPW) was also established resulting in the compartmentalisation of women's health and family planning. Rather than working together, the MoPW and the Ministry of Health engaged in a 'turf war'. Thus, at the operational level, "a hospital's Obstetrics and Gynaecology Department, was not equipped to offer contraception, while a family planning center could not provide comprehensive reproductive healthcare." (3)

In 1994, Pakistan endorsed the International Conference on Population and Development Programme of Action (ICPD-PoA) without any reservations. The lead-up to ICPD, and after, has seen a gradually progressive realisation among government organisations and NGOs about the importance of reproductive health and rights.

In 1994 the National Committee for Maternal Health (NCMH) was created under the chairmanship of the Federal Secretary of Health. (4) Initial efforts since 1996 yielded closer collaboration between the MoH and MoPW. Under the country's 8th Five Year Plan (19931998), the field workers of the two ministries and joint designing of a reproductive health package by the two ministries were better coordinated. (5)

Pakistan's 9th Five Year Plan (1998-2003) built upon the directions and foundations of the previous plan and focused on rural outreach and improved service delivery. Although mother and child care was its stated objective, it did have a broader reproductive health approach covering post abortion services, RTI/STI prevention and treatment, reproductive cancer detection and treatment, and infertility (although these services were only offered at tertiary hospitals). A draft National Reproductive Health Policy was proposed in 2000 using the ICPD definition of RH including the ensuring of reproductive rights and women's empowerment for participation in "all aspects of reproductive decision-making on a basis of equality with men." The policy, however, was never formally approved. Pakistan thus has neither a RH policy nor an SrH policy. The latest National Health Policy, 2001 continues the direction set by ICPD. This policy views health sector investments as part of the poverty alleviation plan, makes a shift from tertiary to primary and secondary health sectors and focuses on health sector reforms.

Having become signatory to the Millennium Summit Declaration and the MDGs, Pakistan is now committed to the latter and its health and population policies are integral to its Poverty Reduction Strategy. MDG 5 and its targets now define the parameters of the maternal health policy and targets: to reduce the maternal mortality ratio by three-quarters and to include indicators on the proportion of births attended by skilled birth attendants, the contraceptive prevalence rate, the total fertility rate, and the proportion of women with at least one ante-natal consultation in the last three years. The new additional indicators (age specific fertility rate among 15-19 years old; and the unmet need for contraception) included after the Millennium Summit 2005 have also been factored in. (6) The Medium Term Development Framework. 2005-2010 (MTDF) that has replaced the Five Year Plans is responsible for the financial framework and the monitoring of MDGs.

Despite the move towards a more progressive approach, demographic targets remain the primary concern of Pakistan's population policies. The vision of the latest Population Policy of 2002 is "to achieve population stabilisation by 2020 through the expeditious completion of the demographic transition that entails declines both in fertility and mortality rates "(7) The policy does strongly reiterate the importance of involving adolescents in the RH service delivery and advocacy programmes, although it refers only to married couples with regard to reducing the unmet need for family planning and reproductive health services. (8)

In Pakistan, there is no specific law or policy that governs the use of contraceptives. The sale and distribution of contraceptives is governed by the 1976 Drugs act, which regulates the import, manufacture and sale of all drugs.

Abortion is illegal in Pakistan unless the procedure is necessary to save the woman's life or provide 'necessary treatment.' (9) The National Reproductive Health Services Package (introduced in 1999 jointly by the Ministry of Health and Ministry of Population Welfare) includes pre and post abortion services among its service components although actual abortion services are not mentioned. There is no specific legislation on STIs or HIV/AIDS. After the detection of the first few AIDS cases in Pakistan (first reported in 1987), the government established the Federal Committee on AIDS through the Ministry of Health in 1987 (10) followed in 1988 by the formation of National AIDS Control Programme. The focus, however, remained on creating awareness and enhancing facilities for blood screening (from 4 percent in 1991-92 to 75 percent during 2000). (11)

1.2 National and local budget allocations for SRHR

The total budget for health is extremely low. However, over the years it has steadily increased and more emphasis is being placed on increasing expenditure for key preventive and primary health care programmes. As a percentage of the GDP, allocation to the health sector has remained fairly stable over the past 6 years at approximately 0.5% (a drop from 0.7% in the 1990s). Although, in absolute terms total government (federal and provincial) expenditure on health has almost doubled from 1999/2000 to 2005/2006, in real terms (taking into consideration inflation and population) government expenditure per capita has remained fairly constant. (12)

Estimating expenditure on reproductive health can be difficult. A serious effort to upscale the health sector allocations in the Federal budget has been made since 2001-02. During the year 2003-04, the total expenditure on health was estimated at Rs. 32.805 billion which is 0.84% of the GNP. This is an increase of 13.8% over the previous year's total expenditure of Rs. 28.814 billion. (13) The priority placed on the RH sector is apparent from the budget allocations for the population welfare programme in the Ninth Five Year Plan: Rs. 10,340 million, substantially higher than the financial allocations of Rs. 7,654 million in the Eighth Plan. The budget utilisation of health or population welfare component has also been higher in the Ninth Plan (80.3%) than in the Eighth (71.5%). (14) UNFPA generated figures reproduced in the Pakistan Population Assessment 2003, indicate that the external resources for population activities registered an increase over the years from US$ 12.7 million in 1994 to US$ 28.1 in 1999 with the reserve flow reaching high point of US$33.5 million in 1996. (15) External donor agencies have shown greater interest in health interventions in Pakistan since 2001-02. They funded 14.7% of the government allocations for health in 2004-05. (16) Funding agencies such as GFATM, USAID, Packard, Hewlett, gates Foundation and UNFPA have been granting funds for the development of proper health facilities and the alleviation of disease.

1.3 Health facilities

Medical facilities in the country have improved over the years. However, there still remains a very large gap between need and availability of resources. Pakistan also faces an inequitable distribution of resources between rural and urban areas. The availability of hospital beds in all medical facilities (12,637) has been estimated at 101,613, which comes to a population bed ratio of 1,536 persons per bed. (17)

The public health care delivery system is divided into four levels;

1. community-based and outreach services. These services are delivered by lady health workers and mainly target women and children in villages and select urban areas. Services consist of immunisation, family planning, sanitation, maternal and child health and malaria control.

2. Primary health care centres which consist of Basic Health Units (BHU) and Rural Health centres usually staffed by one medical officer, a female health worker and non-technical staff. The centres offer basic EMoc services.

3. Secondary health care centres and district and headquarter hospitals usually staffed by a number of doctors and nurses. These hospitals offer higher level services such as comprehensive EMoc, anesthesia, blood transfusions and caesarean sections.

4. tertiary level services are usually based in teaching hospitals where specialist centres are located.

Since an effective referral system to coordinate health service delivery between tiers is lacking, it often results in under use of primary health centres and over use of tertiary services. A situational analysis of management information systems at secondary and tertiary levels found that hospitals are generally overloaded with patients who could have been treated at primary health care facilities. (18)

Another challenge is that there is a lack of women doctors in Pakistan particularly in rural areas. cultural restrictions make it difficult for a woman to have a reproductive health exam conducted by a male doctor. Therefore many women do not seek services from doctors even when they are available.

2

THE BURDEN OF MATERNAL MORTALITY AND BARRIERS TO SAFE MOTHERHOOD

In the past decade, maternal mortality estimates have ranged from 300-700 per 100,000 live births. Recently, the Pakistan Social and Living Standards Measurement 2004-2005 found the MM ratio to be 350 per 100,000 live births. (24) However, determining an accurate maternal mortality ratio for the country is difficult due to unreported cases, rarity of the event and also the high cost of population based studies. (25) Also, there is great variance between figures from hospitals and community based research. (26) currently there is no credible source for measuring maternal mortality and all estimates are derived from mathematical modeling. (27) In August 2006, a national Demographic and Health Survey was launched to collect reliable data on maternal health. The National Institute of Population Studies (NIPS) will be carrying out the survey of 100,000 households. (28)

There are large variations in the figures for MMR which can vary from 17 in a private tertiary care hospital to 2736 in a public tertiary hospital. Variations in MMR between geographical regions are significant. For example, community research by Jafarey "Maternal mortality in Pakistan--compilation of available data" (published in the Journal of Pakistan Medical Association Dec 2002) indicates the range is from 160 in Sindh to 673 in Khuzdar, Baluchistan.

The incidence of maternal death as a result of unsafe abortions is estimated to be high and contributes to approximately 13% of maternal deaths in the country. (29) A study from Karachi estimates that on average, a woman will have at least one abortion by the end of her reproductive life. (30) Most abortions take place in unhygienic conditions and are performed by untrained TBAs and LHWs/nurses.

The majority of maternal deaths are due to direct obstetrical causes, most of these are preventable. In home-based delivery or in hospitals, the leading causes are haemorrhage, eclampsia, sepsis, abortion and obstructed labour. (31) A two-year micro-level study (January 2000-December 2001) conducted at the Ayub Teaching Hospital found that hemorrhage was the leading cause of death (see table below).

This study also found that many deaths occur among women above the age of 30 (16 of the 26 deaths in the study occurred in women above 30) highlighting the need to target older women as well as younger in maternal health programmes. (33)

Home deliveries are still the norm (71 percent) and in rural areas, trained dais and traditional birth attendants were the most commonly cited sources of assistance during delivery (53%) followed by family members/ relatives (26%).34 A rising trend in antenatal care has been reported from 30% in 1990-91 [PDHS] to 36% in 1996-97 [PFFPS] and 51% in 2000-01. The level of care received by women varies between regions. The 2004-2005 Pakistan Social and Living Standards Measurement Survey found that while 56% of women in the Punjab received antenatal care, only 35% of women in Baluchistan did so. (35)

Post-partum care is not as common as ante-natal care although this is also increasing. In 2004-2005, 23% of mothers received a post-natal check-up within 6 weeks of delivery compared to only 9% in 2001/2002. (36)

Research shows that the high level of maternal mortality in Pakistan is due to poor access of women in rural areas and urban slums to peripheral health facilities. (37) Access to facilities is determined to a great extent by socio-cultural factors such as restricted female mobility, availability of transport, non-availability of husbands at the time of delivery complications, low status of women and poverty. Inadequate and inefficient health services, lack of timely referral, and mishandling by TBAs during delivery are other important contributing factors.

In the micro-level study, the following causes of delay were found:

The total fertility rate in Pakistan is 3.28 in 2006 according to GOP estimates; down from 5.64 in 1994 (urban TFR 3.7; rural 5.4). One of the major demographic factors for a high TFR is the young marriage age for females. However, both male and female age at marriage since 1990 has risen with that of females going from 21.6 in 1991 to 22 in 1996-97 and to 22.7 years in 2000-01. According to the most recent data gathered from the Adolescent and Youth in Pakistan Survey 2001-2002 (39) rural females are particularly vulnerable to marriage before age 20 than their urban counterparts (58% vs. 27%). The contraceptive prevalence rate has risen from 18% in mid-eighties to 36% in 2006. (40)

2.1 Policy environment

In Pakistan, there is no specific Reproductive Health or Sexual and Reproductive Health policy. In 1998-99, the Ministry of Health and Ministry of Population Welfare jointly introduced the RH package that comprises of nine components including STIs/RTIs prevention and treatment, reproductive cancer, male involvement, gender equity and equality, prevention of HIV/AIDS, Maternal and neonatal health, and EmOc. However, for sexually transmitted infections, RR and SR remain unaddressed in the RH Package.

MTDF 2005-2010 focuses on rural outreach and improved service delivery through upgraded facilities and provision of services at the doorstep through Lady Health Workers. The emphasis is on mother and child health and care.

2.2 Service Provision

The quality of maternal health care leaves much to be desired. A situational analysis conducted in 1999 by the Society of Obstetricians and Gynaecologists of Pakistan, the National committee for Maternal and Neonatal Health and Ziauddin Medical University, with the assistance of UNICEF Sindh, of 48 tertiary, secondary and first referral facilities of Sindh (20 public and 28 private) showed severe deficiencies. First referral facilities did not have comprehensive EmOc; even basic EmOc was available only during the morning hours. Twenty-four hour coverage for complicated deliveries was not provided at 11% of secondary level facilities. The full obstetric team (surgeon, anaesthetist and theater attendant) was not available in 61% of secondary level facilities. (41)

The health infrastructure in the country lacks the basic requirements to deal with the problem at all levels at primary, secondary and tertiary levels of care. The private and particularly the government health centres not only lack necessary medicines and equipment but also hardly have any qualified and trained gynaecologists/ obstetricians and the necessary paramedical staff in them. The former are unaffordable for the majority of the population and there is no system of health insurance to cover reproductive health care for the poor in the country for deliveries or any other ailments. The public transport system is also very poor especially in the rural areas.

Even though the percentage of women delivering at home is gradually decreasing over the years (71% in 2006 from 85% in 1990-1991) (42) it is the only available option as only 54% of the rural population lives within 6 km from a primary health care centre. Only 20% of women have a skilled birth attendant at delivery. A well-structured network of health care systems in the public sector was put in place in 1970, which looks good on paper but is grossly under-funded (expenditure on health being less than 1 percent of the GNP); it suffers from poor management (e.g. high staff absenteeism) resulting in its under-utilisation. The private sector provides nearly 71.2% of all health care delivery (80% in urban areas and 75.9% in rural areas.) (43)

2.3 National and local budget allocations for safe motherhood programmes

The expenditure on health is less than 1% of the GDP not taking into account expenditures by other departments and the private sector (which has been above 67% of the total government expenditure on health.) (44) There are several major vertical programmes underway across Pakistan since 1999 that do not get reflected in the annual development programmes. The Asian Development Bank committed US$47 million for the Women's Health Project (2000-2005) in 20 districts across Pakistan with the aim of improving the health of women, girls and infants and another US$ 36 million for the Reproductive Health Project (45) (2000-2005) improving RH status of under-served communities in 54 districts. The Northern Health Project financed by a World Bank loan has a commitment of US$ 26.7 million for Northern Areas and Azad Jammu and Kashmir. CIDA, USAID, Save the children-USA, UNFPA, DFID, NEDA, JICA, Asia Foundation, and several donor supported NGO projects also cover different parts of the country. (46)

2.4 Recommendations to the Government:

* Merge the MoPW and MoH for effective formulation and implementation of policies to reduce maternal mortality and unsafe abortions and promote sexual health and rights with strong

M & E and a focus on life cycle approach to women's health.

* Priority has to be accorded to the primary and secondary tiers of health facilities with a clear shift from curative to preventive health care for the disadvantaged, weaker sections of the society especially those in rural areas.

* Make existing infrastructure of BHUs and RHcs fully functional in all districts, tehsils and union councils to provide basic maternal health care incentives and policies for qualified and trained personnel. Establish round-the- clock comprehensive EmOc centres at accessible distances with suitable transport. Mobilise elected representatives of local bodies, by providing them with relevant information for efficient delivery of quality services and budget allocations.

* Ensure availability of affordable essential and nonessential drugs through mechanisms that regulate the quality, uniformity and accountability of services and pricing system of the private sector.

* Develop and implement a National Strategic Framework to address nutritional disorders.

* Acknowledge the incidence of induced and unsafe abortions. Enact as the first step appropriate legislation to ensure safe abortion and legitimize abortion for rape and violence victims.

* Develop a clear policy and an enabling environment to promote public--private health sector partnership.

Develop human resource policy to minimize the existing imbalances in different categories of service providers, especially to improve the production and deployment of midwives, LHWs and nurses.

2.5 Recommendations to donors:

* Support people-centered economic and social sector reforms that remove/reduce income inequalities, secure livelihoods and improve the quality of life of the poor.

* Support government for putting in place mechanisms for regulation, monitoring and ensuring quality of services to the poor and reinforce government's primary role in social sector service delivery. Factor in the negative impact of privatisation and trade liberalisation on the poor in accessing basic social services in donor supported policies and programmes.

2.6 Recommendations to civil society:

* Lobby for a RH policy as a first step towards ensuring a SRHR policy.

* create awareness about RH and RR in the broader framework of women's empowerment among NGOs, women groups, media, political parties, and especially women parliamentarians.

* Act as watchdogs of government policies and programmes. Highlight the gap between intent and implementation. Monitor government's compliance on international commitments.

* Use opportunities for input to government in conceptualisation and planning of RH programmes and policies. Work in partnership with government without compromising on quality and the needs of the poor, and set standards for transparency and accountability. Use opportunity of dialogue and discussion whenever possible.

* conduct independent research to investigate the underlying reasons for maternal mortality in order to recommend policy action to address the issue. Highlight through research and publications the impact on women's health of discriminatory legislation and social practices like forced and exchange marriages, 'honour' killings through research. Share the findings with policy makers and the media.

* Use both the mainstream and alternative print and electronic media including performing arts to raise issues related to women's health, reproductive health and reproductive rights.

Case Study

FOR THE LACK OF AN ULTRASOUND ...

35 year old Amina was a resident of 'Chakra Goth' a remote locality situated at the outskirts of Korangi, Karachi. She had been married for 15 years and had 5 children. When she became pregnant for the sixth time, during the eighth month of pregnancy she started having diarrhoea episodes. She went to the doctor and took treatment but there was no improvement and the problem continued. After a couple of days she started complaining of pain so her sister-in-law, aunt and husband took her to a nearby private clinic. The lady doctor there advised Amina's husband to get her ultra sound done as this was an emergency case, but Amina's husband did not listen to the doctor and instead got infuriated and took her away from there by saying that "you doctors only know how to prescribe lengthy diagnostic investigations".

He then took Amina to the local TBA (dai), Fatima, who performed a vaginal examination on her as a result of which Amina started bleeding. The TBA then gave her an injection and told the family not to worry, as the baby would soon be delivered. The injection had an adverse effect on Amina's brain and her condition further deteriorated. The TBA in the next couple of minutes gave her another 3-4 injections and Amina's condition deteriorated to the extent that she had massive discomfort, lost mental and physical control and started hitting her head against the wall. On seeing this, the TBA told Amina's husband that the case is now beyond her control. Then Amina's husband arranged for a Suzuki car to take her to the hospital but she passed away on the journey.

Source: Case studies conducted in Chakra Goth, Korangi, Karachi. WHRAP baseline research

3

CHALLENGES TO MEETING YOUNG PEOPLE'S HEALTH NEEDS

The youth population (aged 15-24 years) in Pakistan was estimated to be approximately 27 million in 2000. In 2004, the percentage of youths under the age of 15 was estimated to be 38.9% of the total population. (47) According to government figures, the population bracket 0-24 is twice as large as the population aged 25-60, which is the earning bracket. This produces a high dependency ratio and fewer opportunities for the younger generation as compared with their parents. (48)

The concept of adolescence as a distinct period of human development is still fairly new in Pakistan. The reproductive rights of adolescents, particularly those of girls, are often neglected. Adolescents face many age specific disadvantages that are not addressed through formal laws and policies. The ability of adolescents to access the health system, their rights within the family, their level of education, and their vulnerability to sexual violence together determine the state of their reproductive health and their overall well-being.

Despite the fact that approximately 50% of young people are expected to be sexually active (49) and that many adolescents are married, there is a lack of sexual and reproductive health information and services targeted to adolescents. According to the Pakistan Reproductive Health and Family Planning Survey, only one out of ten ever married women reported their mothers having ever discussed bodily changes of puberty with them and over half the women did not consider it important to educate their adolescent daughters about body and emotional changes.

In a Marie Stopes study carried out in 2006, the majority of girls interviewed reported that their mothers are their main source of information for sexual and reproductive health including information about the onset of puberty and in particular, menarche. However, this information is usually only received after the commencement of menarche and only 13% of girls surveyed reported speaking to someone about RH before their first period. (50) Boys surveyed reported that they prefer to consult classmates and friends although only 16% reported consulting someone at the onset of puberty. (51, 52)

Besides the difference in source of information, boys and girls also experience different feelings at the onset of puberty (menarche) with the majority of girls reporting feeling physically or psychologically unwell and nearly half (47%) feeling anxious and afraid. Meanwhile three quarters of boys surveyed reported experiencing positive feelings such as 'feeling good about becoming an adult,' 'liking their moustache and beard' and 'feeling physically strong.' Furthermore, approximately 37% of girls' movements outside the house was restricted following menarche.

There is not much information available about adolescents' knowledge of reproductive and sexual health. A study conducted in 2006 in 20 villages in Lahore sheds some light on adolescent knowledge of SRH. The study found that generally boys have slightly more knowledge than girls about puberty, pregnancy, family planning and sexually transmitted diseases. However, both boys and girls require more information and clarification on their current knowledge.

While often the focus of reproductive health services for women is on maternal care and family planning, young women also require information and education on delayed puberty, delayed or heavy menstruation, irregular discharge and sexual abuse.

The age at marriage has increased for both males and females (27.1 and 22.7 respectively in 2000 from 26.3 and 21.6 in 1999.) (54) Rural females are more vulnerable to marriage before they are 20 than their urban counterparts (58% vs. 27%) with 47% of females (as opposed to 14% males) married before the age of 20 and 14% of females (7% of males) before the legal age. (55) The legal age at marriage is 16 for females and 18 for males and although underage marriages are punishable by law, they are not legally void. (56) The increase in the age of marriage is attributed in some part to the desire of parents to educate daughters but mainly to the rise in poverty and the spread of the dowry practice of dowry even in areas where it traditionally did not exist.

Married adolescent girls are under great pressure to become mothers early, and as a result they have little spacing between marriage and childbearing and use contraceptives to only a limited extent. Therefore, one third of married adolescent girls become mothers in their teens and are in great need of knowledge about reproductive health and access to services. (57)

According to the Pakistan Social and Living Standard Measurement Survey (PSLM 2004/2005), there is a wide gap in education between Pakistani boys and girls. While more adolescent girls are enrolled in school than at any other previous time the gender gap is still huge (54% for girls as opposed to 84% boys.)

While the focus of reproductive health services for women is often on maternal care and family planning, young women also require information and education on delayed puberty, delayed or heavy menstruation, irregular discharge and sexual abuse.

3.1 Policy environment

Pakistan does not have a specific law or policy addressing adolescents' sexual and reproductive health. However, the National Health Policy, Reproductive Health Services Package and Pakistan's population policy includes general and specific provisions relating to the sexual and reproductive health issues and needs of adolescents.

The National Health Policy generally aims to provide sexual and reproductive health services for individuals of all ages and both genders throughout their life cycles. it makes specific reference to the need for implementation strategies to identify and address the reproductive health needs of adolescents, but does not go beyond this directive. The policy also states that reproductive health and health education will be among the Health Ministry's priority programmes. its discussion of reproductive health mentions that all aspects of the reproductive system and their functions will be taught, but the document does not mention sexuality.

The Reproductive Health Services Package identifies the management of reproductive health related problems of adolescents as one of its nine key components. (58) The package gives emphasis to providing information to adolescents about physiological body changes through community based field workers or staff at service facilities. The package identifies teenage pregnancy as a result of early marriage to be a challenge as adolescent girls are often neither physically nor psychologically ready for pregnancy. However, the package only mentions that the "hazards of teenage pregnancy will be highlighted to both boys and girls". it does not refer to pregnancies among unmarried youths or prevention of sexually transmitted infections. Services for youth are expected to be provided by the regular cadre of health professionals and no specific services for youths are mentioned.

Pakistan's population policy of 2002, promises to address "adolescents through population and family life education in the formal and non formal education sector and reach out to young married couples with appropriate media, interpersonal messages, and family planning services. 59 it also states that "youth are the future generation and need to be sensitized about the wide ranging consequences of rapid population growth for the individual, family, and nation and, therefore, the need to build a mindset for responsible parenthood". (60)

To give directions to the efforts of Youth, the Youth Affairs Wing of the Ministry prepared a comprehensive draft National Youth Policy. The draft policy emphasised youth empowerment, education and training, health, environment, culture and art. The policy was presented to the cabinet in 2002 and the cabinet directed the Youth Ministry to reformulate the policy in consultation with all stakeholders. Disappointingly, the draft policy has no mention of reproductive and sexual health needs of youth. After reviewing the policy, the Pakistan Reproductive Health Network--Karachi chapter submitted recommendations to the Youth Ministry regarding this gap. The policy has still not been finalised.

3.2 Service Provision

There is no distinction in government services between general services and those for adolescents. However, there are government children's hospitals and all major facilities have a pediatric section. There are also maternal health and childcare facilities. Generally there is a lack of recognition of adolescent sexual activity outside marriage and therefore there is a gap in services as well. Once married, adolescents are expected to approach regular services. cultural restrictions also challenge specialised services. Unmarried girls utilising a sexual and reproductive health clinic would likely be viewed by the community as "immoral" with the implication that she was engaging in socially unacceptable sexual behaviour. Awareness of adolescent sexual health needs must be increased among the community and policy makers.

The Family Planning Association of Pakistan has been involved in work with youth for several years, and currently conducts a Girl child project under which it offers guidance to adolescent girls, life skills training and RH education. The well-established network of Girl Guides and Boy Scouts in the country is being used to provide counseling and training, particularly under the auspices of the Girl Guides' Shield Programme. Specific RH programmes catering to the special needs of adolescent girls and boys are few but expanding due to the effort of non-government organisations working in the fields of family planning and reproductive health to address the needs of the young population, although outreach remains limited. (61) These are few and located mainly in urban areas.

Sex education is not integrated into the school curriculum. But the demand for sex education among adolescents has been well documented by NGOs. (62) Organisations such as Aahung in Karachi have made major efforts to disseminate material on RH and sexual health. (63) Other NGOs across the country have taken up sexual health issues, particularly due to the available support and funding for HIV/AIDS awareness and prevention projects. Only one out of ten ever married women reported their mothers having ever discussed bodily changes of puberty with them and over half the women did not consider it important to educate their adolescent daughters about body and emotional changes (PRHFPS 2000/01).

3.3 Recommendations:

* Policies and programmes need to be especially designed to meet the needs of adolescents, protect them, and help them to grow into informed, healthy adults. Planners and policy makers need to recharacterize and address the needs of adolescents in Pakistan if they wish the population to enjoy a future filled with possibilities.

* Adolescents must be thought of and treated as a distinct segment of the population with specific developmental and reproductive health needs.

* Research needs to be conducted on the ARH-related health topics, through national sampling and in-depth qualitative work.

* Adolescents must be given access to reliable information on reproductive biology and sex through various programmatic interventions. Issues such as menstruation, masturbation, and general sexuality are fraught with misconceptions and taboos. As a result, young people exhibit an anxiety level about their own sexual development and sexuality that is unhealthy and unnecessary.

Case Study

STORY OF A YOUNG MOTHER ...

15 year old Soofia was residing in Karachi when she fell in love with Saleh and ran away with him. They came to Silro Goth in Shahdadkot, Larakana, got married and started living there with Saleh's cousin and his family, as they could not afford a house of their own. After the marriage, Soofia's husband neglected her, did not take good care of her and mistreated her. The village people tried to persuade him that this is not right but he would not listen to anyone. They even tried to convince Soofia to go back to her parents but she did not agree. Two months later, she became pregnant. She constantly had pain, but since she was so young, lacked prior information and had no elderly family member to guide her, she did not know what to do and how to take care of herself. She did not take care of her diet, used to eat less and did a lot of work, the whole day she ran about here and there doing household chores as well as working in the field with her husband. Her husband also did not care much. As days passed by she became weaker and weaker. Then when the time of delivery came and she started having labour pains, her husband called the local TBA (dai). After examining Soofia, the TBA said that delivery cannot be conducted at home and referred her to the hospital in the city. But Soofia's husband did not have the money to take her. The whole night Soofia cried in pain. Then the next morning her sister in law sold her jewelry to arrange for the money and took her to the hospital. Doctor Maria at the hospital delivered a stillborn baby girl but at the time of delivery Soofia started having fits. The doctor said that because of delay in bringing her to the hospital the infection of the dead fetus has spread in her whole body and this should be treated properly. But her husband did not pay much attention to this and did not get her treated. The village people did whatever they could. During this period she also developed asthma. Six months later as a result of inadequate care and lack of treatment she passed away.

Source: Case studies Silro Goth, Shadadkot, Larkana. WHRAP baseline research.

4

ASSESSING THE IMPACT OF HEALTH SECTOR REFORMS (64) ON WOMEN'S HEALTH AND RIGHTS

In Pakistan, healthcare reforms are intended to decentralise health systems, reduce bureaucracy, and increase cost-effectiveness and efficiency in part by reorganising services, streamlining management, and allocating resources to better meet local needs.

Ten specific areas have been identified by the Ministry of Health under their Progress on Agenda for Health Sector Reforms in March 2004. These are:

i) Reducing widespread prevalence of communicable diseases

ii) Addressing inadequacies in primary/secondary health care services

iii) Removing professional/managerial deficiencies in the District Health System

iv) Promoting greater gender equity

v) Bridging basic nutrition gaps in the target population

vi) correcting urban bias in health sector

vii) Introducing required regulation in private medical sector

viii) creating Mass Awareness in Public Health matters

ix) Effecting Improvements in the Drug Sector

x) capacity-building for Health Policy Monitoring

4.1 Financial Requirements for Action Plan

The Ministry of Health estimates that a total financial requirement for the on-going and new projects of MoH to be Rs. 22.211 billion for the period 2001-04 and Rs. 95.353 billion for the period 2001-11. The estimates are summarised in table 11.

4.2 Health Sector Expenditure in Pakistan

Public sector expenditures in health have been lower than other countries in the region. It is estimated that the total expenditure on health (THE) in Pakistan is US$16 per capita out of which the total government health expenditure (GHE) is US$ 4 per capita. This compares unfavorably with the figure of US$ 34 per capita for a package of essential health services as proposed in the recent WHO report of the Macroeconomic commission on Health. Table 12 portrays a comparison of total and government health expenditure in relation to selected health system performance indicators for Pakistan and some countries of the region.

As a percentage of the GDP, the GHE has not exceeded 0.8%. For comparison, the corresponding average figure for all low-income countries in the 1990-98 period was 1.3% of the GDP.

The budgetary allocations for the health sector have seen an increase during the last few years. The total outlay for health improvement programmes during 2001-02 was Rs. 25.406 billion (Rs. 6.688 billion for development and Rs. 18.717 billion for recurring expenditures) whereas the budget allocation for the FY 2003-04 was Rs. 32.805 billion.

A serious effort to upscale the health sector allocations in Federal PSDP has been made since 2001-02. in the year 2001-02, an additional allocation of Rs. 2 billion was allocated most of which was utilised through national priority health programmes. in the year 2003-04, record amounts of Rs. 4.3 billion has been allocated in Federal PSDP. The actual implementation of health sector allocations in federal PSDP for the last 8 years is given in the table below.

Previous health strategies were unsuccessful because a major share was spent on tertiary health care facilities to which only 1% of the population had access, with the result that the health facilities for rural and poor populations have been compromised. The health system's ability to respond and provide adequate preventive and curative services continues to be limited.

The medium term strategy of the government is focused on raising public sector health expenditures through prevention and control of diseases, reproductive health, child health, and nutrient deficiencies. The thrust of public expenditure is geared towards the primary and secondary tiers of the health sector, providing basic health to the poor and rural segments of the population.

4.3 Impact on access to services

Poor women have identified insufficient access to health care as a constraint to their utilisation. Failure to use services has been blamed on women's illiteracy and cultural and religious beliefs. Services are insensitive to women's needs, for example, the distance of the health facility from home or the unsuitable opening hours. Women prefer private facilities and report better treatment as they receive respect, sensitive counseling and consultation. (65) The reason for limited or non-utilisation of services may also lie in restrictions to leave the home imposed by the husband, male kin and other influential family members including the mother-in-law. The wide socio- cultural gap that exists between users and providers of health services also affects access. it must be noted that while there has been a long standing recognition of these problems, systems of implementation have been flawed and service delivery continues to be severely lacking. The persistence of poor social indicators, poor HDI ranking, improvement in data collection, findings of independent research, MDGs and the linking of external funds to performance have combined with Health Sector Reforms to bring about change.

In keeping with the shift from family planning to reproductive health, efforts have been made to bring in a reproductive health care approach to women's health. Availability and access to female health care providers has increased substantially during the 1990's including the introduction of the Lady Health Workers (LHWs) Programme. However availability of skilled birth attendants, LHWs and nurses still remains very low. it is believed that availability, access to and quality of basic and comprehensive obstetrical services and their utilisation are also low. Availability and access to family planning services has been enhanced through expansion of the family planning services, outreach programme through over 70,000 LHWs and the social marketing of contraceptives. The improved availability is reflected in gradually increasing CPR of 32%, but, there is still a large unmet need (33%) with more than half the women desiring no more pregnancies. Despite large urban-rural differentials and a smaller male-female differentials, immunisation coverage of pregnant women and children has improved, yet remains unacceptable, with 57% of children covered. The infant mortality rate of 77.1 per 1,000 live births is still higher than the averages for low-income countries and South Asia by 10% and 16%, respectively.

The government aims to promote gender equity through targeted interventions like increasing the number of Lady Health Workers and improving maternal health care. LHWs are covering the underserved population at the primary level to ensure family planning and primary health care at the doorstep through an integrated community based approach. Additional programmes include Directly Observed Treatment Schedule (DOTS) strategy against TB; Roll Back Malaria (RBM) approach in combating malaria, measures for preventing the spread of Hepatitis B, elimination of neonatal tetanus and polio, HIV and AIDS through immunisation and public health campaigns and institutional federal-provincial partnership in the war against disease. Other steps include strengthening of primary health care, training and re-training of medical staff, provision of emergency obstetric care facilities, instituting public-private partnerships, granting administrative and financial autonomy to teaching hospitals, establishing health boards and village health committees, reorganising district health offices, improving hospital administration and their financial management and the proper regulating of the private sector.

The private sector is the major provider of health services in Pakistan, but remains largely unregulated. More recently under the HSR and public-private partnership, contracting of Basic Health Units to NGOs has been tried out with the designated budget allocated to the NGO. The initial result shows an increase in efficiency and rapid increase in the utilisation of the facilities. However some of the other functions that a BHU fulfilled, for example, that of being the training institute of LHWs has been curtailed in the contracted BHUs. Similarly if the BHUs are contracted to private doctors (which is being considered) then the profit motive is likely to undermine the provision of service; a not- for- profit does not have such a motivation. The matter of increasing PPP contracting of BHUs is still under debate and discussion.

Devolution of government has also had an impact on healthcare. Pakistan has undergone a process of devolution and in 2000 under the Devolution Plan of the Government of Pakistan, districts received administrative and financial autonomy. Districts are now responsible for using local evidence to identify healthcare needs and to formulate health strategies, programme and interventions. in some instances, devolution has meant that resources are being allocated more appropriately and reaching the local community more effectively. Also some vertical programmes provide funds for specifics for example, the Health Sector Reform programme in Punjab prioritises "improving of quantity and quality of" BHU and RHC. Under key interventions this involves better incentives for public sector health staff of these services to ensure availability of health providers; remove deficiencies of infrastructure and equipment, revise medicine lists etc.

In Conservative areas, the result may be different. Data indicates that services have improved in NWFP and Baluchistan which are relatively more conservative areas of the country. However from time to time there are news reports which highlight problems. For example, in NWFP male paramedics (ultra sound, etc.) were reportedly not allowed to attend to female patients. in the tribal belt of Pakistan, the most conservative area, even polio drops cannot be administered as the tribal leaders have declared these as 'western' ploy to promote family planning. in this way devolution, by giving districts more autonomy, can cause problems for public healthcare provision.

In conclusion, while health sector reforms are needed, they need to be determined by evidence specific to Pakistan with good monitoring mechanisms to track performance.

5

GENDER, ECONOMIC AND SOCIO-CULTURAL OBSTACLES TO, AND CIVIL AND POLITICAL FACILITATING FACTORS FOR IMPROVING SRHR

5.1 Cultural, religious and economic factors affecting SRHR

Socio-cultural taboos attached to the word "sex" are the main obstacles, globally in the way of SRHR information-dissemination. in Pakistan, society is predominately conservative, bound by many social and cultural taboos. There are many things that people simply don't do because they are considered wrong by society. Society determines the way people live their lives.

Gender discrimination exists in access to food, health care and education, which results in lower nutritional status of women and girls. A higher incidence of malnutrition has been reported in females than in males and differences are reported in access to health care (with males having higher access). These factors are particularly marked in low-income households. The nutritional status of the population, especially of pregnant women, is highly unsatisfactory. The National Nutritional Survey 2001-2002 shows that 12.5% of mothers and 16.1% of lactating mothers are malnourished. Iron deficiency was found in 45% mothers. Clinically, anaemia was present in 29.4% mothers, 22.5% being moderate to severely anemic. in 1995 the Federal Bureau of statistics had reported the calorie intake of pregnant and lactating women to be 87% and 74% of the recommended calories respectively. This has an impact not only on maternal but also child health, contributing significantly to low birth weight babies.

In Pakistan, women and youth especially in rural areas have little or no participation in the decision-making process. (66) They have limited power to make important decisions affecting their lives. Women are particularly restricted especially in marriage decisions.

Women regardless of socio-economic status, are restricted to a life that largely centres on home and chores; males have much greater exposure to the outside world. Mobility especially in rural areas is severely constrained for women. Young women need to be accompanied anywhere outside the home, apart from when they visit the neighbours. While the older women can go out unaccompanied, they also do not do so as often they are not used to it. This has direct implications on women with regards to attainment of education, access to health facilities, opportunities for work, and recreation and social networks.

Gender roles are largely determined by culture, but religious factions play a role in reinforcing tradition. They position their policies as being a positive force for women, emphasising that they serve to protect women's dignity and honor. The main Islamic parties in Pakistan today are careful to put a "women friendly" face on their actions, stressing that they are not interested in a programme of "Talibanization." instead, they focus on the perceived social benefits of maintaining a more traditional role for women in society as being pro-family. Others label such policies as reactionary and anti-female. Usually their focus is on the discriminatory legal environment stemming from Shari'a, but other policies catch their ire too, such as gender segregation and the Islamists' hostility towards family planning. Pakistan's constitution guarantees women equal rights, and empowers the government to take affirmative action to protect and promote those rights. However, over the years, parallel Islamic legal systems have been promoted which undermine those rights, like the Federal Shari'a Court (FSC) established by General Zia ul-Haq in 1980. The gender bias of Shari'a is undeniable. Women have unequal rights to inheritance, termination of marriage, minimum age of marriage, and natural guardianship of children. Polygamy is allowed, and there are grossly inadequate provisions for women's financial security after divorce. Pakistan's controversial Hudood Ordinances, (67) particularly with regard to Zina (sex), are also discriminatory. By blurring the line between rape and adultery, the Zina Ordinance creates the possibility that a woman can be convicted of adultery if she cannot prove rape. The discriminatory nature of Islamic legal reforms for women in Pakistan is clear, but the extent of their impact is hard to measure. Islamic legal reforms and the Hudood laws in particular have served to reinforce male social control over women, limiting female bargaining power within the family and their control of resources. This has also contributed to an environment where violence against women is not sufficiently discouraged. (68) However, women have recently gained more rights within the law. On November 15th Pakistan's National Assembly passed the Protection of Women Bill (PWB) 2006 which significantly reformed the laws governing rape, adultery and other sexual crimes. The PWB was signed into law by the President on December 1st, 2006. With the new law, women survivors of rape and other sexual crimes can not be prosecuted for adultery. in addition, the concept of statutory rape has been reintroduced and the age of majority has been changed from 14 to 16 years for girls. Although the new bill does not meet activists' demands for a total repeal of the 'Hudood ordinances', it is a significant step forward. (69) Recently, questions have been raised with regards to the shortfalls of the Protection of Women Bill. Specifically, women activists question why the law uses the ambiguous term "puberty" to define adulthood and renders girls as young as nine to be prosecuted as "adults" for sexual crimes. (70)

in Pakistan, political change, thrice since 1994 ending with a military coup in 1999, has been turbulent bringing into the political mainstream extremist religious parties. Forming governments in two of Pakistan's four provinces following the general elections of 2002, these parties are intolerant of the rights of women and minority communities, and do not hesitate to use arms for promoting their agendas. This has been witnessed in NWFP where NGOs working for female literacy have been threatened and attacked.

Pakistan has rightly begun to focus its limited health resources on primary health and basic facilities in rural areas. However, to the extent that Islamization limits women's ability to access resources, it could have a negative impact on the pressing need to improve community health and slow its population growth rate. A recent study by the Population Council shows how conservative norms already constrain female access to health care in rural Pakistan. 96% of females aged 15-24 years need permission to travel to a nearby health outlet. The primary reasons given for travel restrictions all relate to family reputation and family tradition.

Another factor that could hinder Pakistan's economic development is the Islamists' antipathy to family planning. Providing Pakistan's female population with access to basic family planning services is critical. Population growth must be slowed if Pakistan is to deliver a higher per capita GDP, yet the Council for Islamic ideology (CII) recommends that family planning should be withdrawn: the Council claims that it is un-Islamic and that increasing population is not a burden on the country. (71)

In Pakistan 47 million people (a third of the whole population) are living below the poverty line. (72) The level of poverty worsened over the years increasing from 27.7% in 1993-94 to 30.6% in 1998-99 and reaching 31.8% in 2003. (73) inequality also intensified in the 1990s, with income distribution in urban areas being consistently more unequal than rural areas.

In 2002, the income share of the poorest 20 percent was 9.3% while the share for the richest 20 percent was 40.3%. The ratio of the richest 10% to the poorest 10% was 6.5. (74)

Poor governance is one of the key underlying causes of poverty in Pakistan. Corruption and political instability, which are both manifestations of governance problems, have resulted in waning business confidence, deteriorating economic growth, declining public expenditure on basic entitlements, low efficiency in delivery of public services, and a serious undermining of state institutions and rule of law, which in turn translates into lower investment levels and growth. The effects of poor governance have compounded the economic causes of rising poverty such as the decline in GDP growth rate, increasing indebtedness, inflation, falling public investment and poor state of physical infrastructure. At the same time, social factors such as the highly unequal distribution of land, low level of human development, and persistent ethnic and sectarian conflicts are also obstacles to the achievement of long term-sustained development.

5.2 Enabling factors within the country context

The provincial and national legislative assemblies are trying to amend the existing anti-women laws and to adopt new legislation to curb violence against women. The Supreme Court has also empowered women to marry of their own free will, without the approval of parents or the legal guardian. The government is forming complaint cells in the Women Police Stations and crisis centres to provide free legal and medical aid to victims of violence. in the year 1999 six women's crisis centres were set up by the government but none in any government hospitals. (75) Within six months of being established 780 women had approached the centres. Of these, 291 were seeking legal assistance, while 60 were looking for shelter and 55 needed medical aid. (76) These are in addition to government funded and managed women shelters (Dar ul Amans) which operate more as sub jails. A number of shelters have also been set up by NGOs in view of their need among women. (77)

The local government Devolution Plan 2001 reserves 33% of seats for women for the first time to be directly elected in local bodies. Officials say that the devolution plan marks a watershed in the political empowerment of women and that their economic empowerment will also increase significantly due to specific efforts like microcredit schemes.

Media awareness has also increased on women related issues, with greater coverage by the print and electronic media. The government and independent channels have aired donor-funded plays highlighting gender issues, such as violence, and regularly run discussion programmes on sexual harassment at the workplace, violence against women and other issues. Allocation of free time on television, for relaying public service messages, have helped considerably in publicizing the need for contraception, in safe guarding maternal health, and caring for the girl child.

The Pakistan NGO Forum is the largest network of NGOs for safeguarding the interests of the sector (estimated membership: 2500). Formed in the mid-90's following government steps to bring in restrictive and controlling legislation it has managed to defer the passage of the law by successive governments through its mobilisation and active lobbying.

NGOs in Pakistan have proliferated to over 56,000 over the last decade. One important development is that now the NGOs are looking at issues from the human rights perspective. The NGO sector has shown its ability to mobilise and advocate for policies and change. in the last decade NGOs have developed communication mechanisms as well as built thematic and regional networks for information sharing, advocacy and solidarity. This enabled the provision of support, e.g., to organisations that were subject to physical attacks for carrying out female education projects in NWFP. There is also greater cross-thematic interaction among NGOs, for instance the PRHN and the Pakistan Micro Finance Network (providing credit to grassroots organisations and women).

6

MOBILISING FOR CHANGE

There is a need to address women's reproductive health needs specifically instead of just focusing on demographic goals. The reproductive health programme should include gender sensitisation and the attainment of gender-equity as an integral and essential component. This could be achieved through various levels and ways:

6.1 Policy

* Merge the MoPW and MoH for effective formulation and implementation of policies to include reduction of maternal mortality and unsafe abortion, and promote sexual health and rights, bodily rights and adolescent SRH with strong M & E and a focus on a life cycle approach to women's health. Gender- based barriers that have cultural roots should be addressed in this component, as their perpetuation will hinder the availability of reproductive health care for women.

* Begin dialogue with policy makers to promote women's health and gender equality.

* Give specific attention, with legislation, policies and strongly implemented programmes, to improving women's currently low gender status. Reinstitute the quota for jobs for women in government service, implement the recommendations of the inquiry Commission and NCSW to repeal discriminatory legislation that contribute to the perpetuation of discrimination and violence against women.

* Ensure availability of affordable essential and nonessential drugs through mechanisms that regulate the quality, uniformity and accountability of services and pricing system of the private sector.

* Enact appropriate legislation to ensure safe abortion and legitimise abortion for violence and rape victims.

6.2 Advocacy

* Address elimination of violence against women (VAW) as a specific human/women's rights issue in the health programme. This could include components such as studying the reasons or causes underlying cultural and social discrimination of women; training health personnel to detect gender based violence and sexual abuse; promoting gender equality and equity; enhancing public awareness about YAW via publicity in print and audio visual media; and street theatre.

* Encourage the involvement of activist groups in women's health education activities to promote improved decision making by women.

* Initiate public education and activities through the media to enhance public understanding of reproductive health and gender sensitivity via the media.

6.3 Information Education Communication (IEC)

* Use audiovisual material and street theatre as the presently high rates of female illiteracy are a hindrance to awareness on various women's issues.

* Address unequal power relations within the household and the consequent gender imbalance and inequity, public IEC materials should be designed to increase awareness about gender issues of health providers, promote and provide training for gender sensitisation, with the aim of gradually reducing/eliminating gender disparities.

* Develop IEC materials with a special focus on women's nutritional needs.

* Publish informative booklets with basic information about health.

* Provide information on sexuality, reproduction, contraception, STDs, infertility and gender roles, and about sites for service delivery.

6.4 Interpersonal Communication

* Ensure delivery of communication messages for gender--sensitisation directed towards the low-income population in Pakistan.

* Encourage a direct interaction of the select target audience through interpersonal communication vehicles i.e. peer outreach workers, community/ social mobilisers, etc.

* Promote an integrated programme along with the government LHW programme because the LHWs are easily trusted by housewives and women as they belong to the same social strata and community.

6.5 Service Delivery

* Improve the present system of supplies and equipment that does not meet the requirements of health personnel and women.

* Reduce gender disparities in staffing and hospital bed strength at health care centres.

* Establish and promote "Well Women Clinics".

* Ensure that the initiative of enhancing training and deployment of community based health workers is effectively implemented.

* Encourage women to attend health facilities and provide comprehensive health information to women.

* Encourage women to seek post-abortion care with widely publicised comprehensive information and follow up.

* Encourage greater dialogue about contraception among women and men, through counseling by community-based health workers.

Deal with as many reproductive health issues as possible and provide relevant facilities at the same service outlet.

6.6 Training Curriculum

* Training curriculum for health personnel should include interpersonal skills development, to enable better and fruitful interaction with women during counseling and consultation.

* Training curricula for community based health attendants should also stress the significance of nutrition for women.

* Inclusion of gender concepts into policies and curricula, especially human resource training institutions for doctors, nurses, paramedics, other health and social service providers.

ENDNOTES

(1) The term 'Human Rights' refers to the rights accorded by the Universal Declaration of Human Rights which was adopted by the General Assembly of the United Nations in 1948 as a common standard for all people and nations. (http://www.un.org/ rights/)

(2) Siddiqi. S et al. 2004 "Pakistan's maternal and child health policy: analysis, lessons and the way forward. Health Policy 69. 117-130.

(3) Saeed, Hilda, 1999. "Country Study of Pakistan": Taking up the Cairo Challenge. ARROW. Kuala Lumpur. p. 85

(4) NCMH is "the focal technical and advisory body for matters relating to women's health in general and safe motherhood in particular". it has representatives from all the four provinces and has been active in creating awareness, formulating a national maternal and perinatal health policy and a national plan for action with funding from UNICEF-Pakistan. Dr Asma Fozia Qureshi and Dr Yasmeen Sabeeh Qazi, Maternal and Neonatal Health in Pakistan: A desk Review. Islamabad. 2003 (unpublished) p.19

(5) The package included: Family Planning Counseling, IEC and Services; Perinatal/prenatal care, safe delivery and post natal care; infertility prevention and treatment; Prevention and treatment of RTIs, STIs and HIV/AIDS; information and counseling on human sexuality and responsible parenthood.

(6) Sania Nishtar. 2007. Health indicators in Pakistan: Gateway Paper II. Heartfile: Islamabad. p.277

(7) The major goals of the Pakistan Population Policy include attaining a balance between resources and population within the broad parameters of the ICPD paradigm; increase awareness of the adverse consequences of rapid population growth at the national, provincial, district and community levels; promote through improvement in access and quality of reproductive health services; reduce population momentum through delay in the first birth, changing space patterns and reduction in family size desires.

(8) Population Policy of Pakistan, 2002.

(9) Pak. Pen. Code S 338. See also Time To Speak Out: illegal Abortion and Women's Health in Pakistan, supra note 363, at 23

(10) See Sharaf Ali Shah, et. al. 1998. HIV Working Group, AIDS in Pakistan 15 (1998), see also Joint United Nations Program on HIV/AIDS (UNAIDS), the United Nations system in Pakistan, United Nations Statement on HIV/AIDS in Pakistan 11 (2002)

(11) GoP-UNFPA, 2004. Pakistan Population Assessment 2003. Islamabad. p. 42

(12) Siddiqi. S et al. 2004 "Pakistan's maternal and child health policy: analysis, lessons and the way forward. Health Policy 69. 117-130.

(13) Pakistan economic Survey 2003-2004

(14) GoP-UNFPA, 2004. Pakistan Population Assessment 2003. Islamabad. p.74

(15) Ibid. p.80

(16) Sania Nishtar. 2007. Health indicators in Pakistan: Gateway Paper II. Heartfile: Islamabad p. 236

(17) Pakistan Economic Survey 2003-2004

(18) Situation analysis of existing MIS at secondary and tertiary hospitals. http://www.pakistan.gov.pk/ divisions/Contentinfo.jsp?DiviD=25&cPath=254_ 260&ContentID=1643

(19) Pakistan Economic Survey 2005-2006

(20) Reservation on CEDAW: Any dispute between two or more states parties concerning interpretation or application of the present Convention which is not settled by negotiations shall, at the request of one of them, be submitted to arbitration. if within 6 months from the date of the request for arbitration the parties are unable to agree on the organization of the arbitration, any one of those parties may refer the dispute to the international Court of Justice by request in conformity with the statue of the court.

(21) The Optional Protocol on the sale of children, child prostitution and child pornography draws special attention to the criminalization of these serious violations of children's rights and emphasizes the importance of fostering increased public awareness and international cooperation in efforts to combat them.

(22) The Optional Protocol on the involvement of children in armed conflict establishes 18 as the minimum age for compulsory recruitment and requires States to do everything they can to prevent individuals under the age of 18 from taking a direct part in hostilities.

(23) See NGO Coordinating Committee for Beijing+5, Pakistan NGO Review Beijing+5, Women 2000: Gender Equality, Development and Peace for The 21st Century.

(24) Farooq, Nasir et al. 2006. An Assessment Study o f Maternal Mortality Ratio Databank in Five Districts of North Western Frontier Province Pakistan. Journal of Ayub Medical College Abbottabad, 18(2) 64-68. http://www.ayubmed.edu.pk/JAMC/ PAST/18-2/nasirfarooq.pdf

(25) Ibid.

(26) Hospital based studies from different provinces of Pakistan estimate MMR to range from 670-4,472 per 100,000 live births and community based research on maternal mortality have estimated MMR ranging from 281/100,000 live births in the urban slums of Karachi to 673 in rural Khuzdar district of Balochistan.

(27) Mumtaz, K. 2007. "Reducing the gender gap". (unpublished).

(28) The Daily Times. "2.7 million demographic health survey launched." August 10, 2006. http://www. dailytimes.com.pk/default.asp?page=2006%5C08 %5C10%5Cstory_10-8-2006_pg11_1 accessed on September 2, 2007.

(29) Population Council, National study on unwanted pregnancy and post abortion complications in Pakistan. www.popcouncil.org/rh/ PakresearchUnwantedPreg.html

(30) Saleem, S and F. Fikree. 2001. "Induced abortion in low socio-economic settlements of Karachi, Pakistan: rates and women's perspectives". Journal of Pakistan Medical Association, 51 (8) 275-279.

(31) Pakistan Reproductive Health and Family Planning Survey 2000-01

(32) Begum, S., A. Nisa, I. Begum. 2003. "Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors". Journal of Ayub Medical College Abbottabad. 15(2)

(33) Ibid.

(34) Pakistan Social and Living Standard Measurement Survey (PSLM) 2004/2005

(35) Ibid.

(36) Ibid.

(37) Focus Group Discussions and case studies conducted in Silro Goth Shahdadkot Larkana, Chakra Goth Korangi Karachi and Jughian Siyalah Sheikhupura Punjab (WHRAP Baseline Research).

(38) Begum, S., A. Nisa, I. Begum. 2003. "Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors". Journal of Ayub Medical College Abbottabad. 15(2)

(39) Sathar et al. 2003. Adolescent and Youth Survey Pakistan, 2001-2002. p.104; 87-88

(40) National institute of Population Studies (NIPS). 2006

(41) Siddiqui, R., T. Rizvi, S. Jafarey. 1999. "Situation analysis of Emergency Obstetric Care (EOC) in four districts of Sindh". Journal of College of Physicians Surgeons of Pakistan. (4):187-9. Ziauddin Medical University, Karachi.

(42) Asian-Pacific Resource and Research Centre for Women (ARROW). 2005. "Country Study: Pakistan", Monitoring Ten Years of ICPD implementation, The Way Forward to 2015. Kuala Lumpur, Malaysia

(43) Pakistan Social and Living Standard Measurement Survey (PSLM) 2004/2005

(44) Sania Nishtar. 2007. Health indicators in Pakistan: Gateway Paper II. Heartfile: Islamabad. p.227

(45) The Reproductive Health Project intends to cover: comprehensive FP services for females and males, maternal health care including safe motherhood and pre and post abortion care for complications, infant health care, prevention and management of RTIs/STDs and HIV/AIDS, management of RH related problems of adolescents, management of RH problems of women, management of infertility, detection of breast and cervical cancers and management of RH related issues of men.

(46) Dr Asma Fozia Qureshi and Dr Yasmeen Sabeeh Qazi, Maternal and Neonatal Health in Pakistan: A desk Review. Islamabad. 2003 (unpublished)

(47) Human Development Report, 2004.

(48) Azariah and Reickenback, 2001.

(49) National institute of Population Studies, 2001.

(50) Marie Stopes international. 2006. "Adolescence in Pakistan: sex, marriage and reproductive health". into View.

(51) Ibid.

(52) Shaikh, B.T. and S.T. Rahim. 2006. "Assessing knowledge, exploring needs: a reproductive health survey of adolescents and young adults in Pakistan." European Journal of Contraception and Reproductive Health Care. 11(2): 132-137.

(53) Ibid.

(54) PRHFPS 2000/01 Preliminary report: 12

(55) Sathar et al, 2003. Adolescent and Youth in Pakistan 2001-2.p. 104; 87. The AYP is a survey of adolescents and youth ages 15-24 in a nationally representative sample across Pakistan.

(56) Centre for Reproductive Rights. 2004. Pakistan Chapter. Women of the World: Laws and Policies Affecting Their Reproductive Lives: South Asia.

(57) Durrant, V. 2000. Adolescent Girls and Boys in Pakistan: Opportunities and Constraints in the Transition to Adulthood. Research Report No.12. Islamabad: Population Council.

(58) Pakistan Reproductive Health Service Package. Ministry of Health and Population Welfare. 1999.

(59) Ministry of Population Welfare. 2002b:13

(60) Ibid.

(61) For details see Ayesha Khan, June, 2000. Adolescent and Reproductive Health in Pakistan: A Literature Review. Islamabad: UNFPA/ Population Council.

(62) Ibid, pp. 17-26

(63) For examples, see Aahung, 2002, Promoting Holistic management in Sexual Health, Karachi; Aahung Annual Report, 2001; Shireen Issa, ed., 2001, Body, Mind and Spirit in Sexual Health: National Conference Report, Karachi, Aahung.

(64) The term Health Sector Reforms refers to the package of reforms which are led by the World Bank and funded by DFID and the Asian Development Bank.

(65) FGDs WHRAP baseline research

(66) Ibid.

(67) The Hudood Ordinance is a law in Pakistan, intended to implement Muslim Shari'a law, which enforces punishments mentioned in the Quran and sunnah for a number of crimes, including extra-marital sex (zina[1]), the drinking of alcohol, and theft. Source: _http://en.wikipedia.org/wiki/Hudood_Ordinance

(68) UNFP and PRB, Country Profiles for Population and Reproductive Health, p. 146.

(69) Shirkat Gah-Women Living Under Muslim Laws /Newsheet/ December 2006 (Vol. XV111 No. 4)

(70) Shirkat Gah Womens' Resource Centre., 2007. Talibanization and Poor Governance: Undermining CEDAW in Pakistan. 2nd CEDAW Shadow Report.

(71) Misra. Rise of Religious parties in Islam.

(72) National institute of Population Studies. 2003

(73) Ibid.

(74) Human Development Report, 2006.

(75) in Islamabad, Karachi, Lahore, Peshawar, Sahiwal and Vehari.

(76) HRCP, 2000. The State of Human Rights in Pakistan. Lahore. p. 175

(77) Shelters for women set up by NGOs include Panah Karachi and Lahore; AGHS' Dastak in Lahore and Aurat Foudation's Mera Ghar in Peshawar.

Table 1 Health facilities and human resources,
2005-2006 (19)

Type of Facility/Resource                   Total Number

Hospitals                                       946
dispensaries                                    4554
basic Health Units and sub health centres       5290
Maternal child Health centres                   907
Rural Health centres                            552
tuberculosis centres                            289
Registered doctors                            118,160
Registered nurses                              33,427
Population per doctor *                         1310
Population per nurse *                          4636

* Based on a population of 155 million

Table 2. Some significant national development
indicators:

1  Population of Pakistan 2004                      154.8 million

2  Current estimated population as of September     161.1 million
   2007

3  Population in rural areas (% of total) 2004          65.5%

4  Population under age 15 (% of total) 2004            38.9%

5  Annual population Growth rate 1975-2004              2.8%

6  Total Fertility Rate 2000-2005                       4.3%

7  Life expectance at Birth (both sexes) 2004        63.4 years

8  CPR 2003                                              34%

9  Adult literacy rate (%ages 15 and older) 2004        49.9%

10 infant mortality rate (per 1,000 live births)         89
   Poorest 20%. 1990

11 infant mortality rate (per 1,000 live births)         63
   Richest 20%. 1990

12 Under 5 mortality rate (per 1,000 live births)        125
   Poorest 20%. 1990

13 Under 5 mortality rate (per 1,000 live births)        74
   Richest 20%. 1990

14 Maternal Mortality Ratio (per 100,000 live            530
   births)1990-2004

Source: Human Development Report, 2006 (Indicators 1, 3-14);
Population Census Organisation of Pakistan; 2007 (Indicator 2)

Table 3. National gender-related indicators

1  Male Population 1998 (of total population of         52%
   132.3 million)

2  Female population 1998 (of total population          48%
   of 132.3 million)

3  Sex Ratio 1998 (males per 100 females)              108.5

4  Sex Ratio 2005 (males per 100 females)               106

5  Human Development Index (HDI) value 2004            0.539

6  Gender-related Development Index (GDI) value        0.513
   2004

7  Gender Empowerment Measure (GEM) value 2004         0.377

8  Female adult literacy rate 2004                      36%

9  Labour force participation 2005-2006            50.28% (males)
                                                  13.29% (females)

10 Women in government at ministerial level             5.6%
   (as % of total), 2005

11 Seats in lower house or single house held by         10%
   women (as % of total), 1990

12 Seats in lower house or single house held by        21.3%
   women (as % of total), 2006

13 Seats in upper house or senate held by women         17%
   (as % of total), 2006

Source: Human Development Report, 2006 (Indicators 5-12);
Pakistan National Census, 1998 (Indicators 1-3; Pakistan
Demographic Survey, 2005 (Indicator 4)

Table 4. Infant Mortality Rates according to gender

                     Infant Mortality Rate (per 1000 live births)
Survey
               All Areas            Urban Areas          Rural Areas

          Both                 Both                 Both
          Sexes  Male  Female  Sexes  Male  Female  Sexes  Male  Female

PDS 2005  76.7   84.8  67.6    67.1   76.2  56.7    81.2   88.9  72.7
PDS 2003  76.2   81.1  71.0    67.2   69.7  64.4    80.6   86.6  74.1

Source: Pakistan Demographic Survey (PDS), 2005.

Table 5. Some international and regional conventions
and agreements that Pakistan is party to:

                                       YEAR OF         RESERVATIONS
CONVENTIONS/AGREEMENTS               RATIFICATION        (IF ANY)

CEDAW (Convention on the                 1996         Para 1 Article
Elimination of All Forms of                              29 (20)
Discrimination Against Women)

Convention on the Rights of the          1990
Child

Optional Protocols to the
convention on the Rights of the      Not ratified
Child on Prostitution and Child
Pornography, (21) and regarding
Children in armed conflict (22)

International Conference on              1994
Population and Development

Beijing Declaration and Platform         1995       Para 97 & 232 (f)
For Action                                          relating to sexual
                                                     and reproductive
United Nations Millennium                2000       health issues (23)
Declaration

SAARC Convention on Preventing and       2002
Combating Trafficking in women and
Children

Table 6: Causes of Maternal Mortality (32)

CAUSE                        No.      %

Haemorrhage                   9     34.6
Hypertensive disorders        8     30.7
Sepsis                        5     19.2
Anaesthetic complications     3     11.5
Hepatic encephalopathy        1      3.8

Table 7: Causes of delay in relation to maternal mortality (38)

Cause                                  No.      %

Lack of transport                        8    30.7
Poverty and inability to afford cost     7    26.9
Familial taboos                         10    38.4
Ignorance about health care facility     1     3.8

Table 8: Level of knowledge regarding STIs/AIDS (53)

STIS/AIDS                            BOYS      GIRLS
                                    (n=191)   (N=208)

Knowledge about the sign and
  symptoms of STIs/AIDS               18%       13%
Knowledge of spread of STIs/AIDS      64%       46%
Knowledge of prevention of
  STIs/AIDS                           48%       32%

Table 9. Contraceptive knowledge and practice among
married female adolescents aged 15-19 (in %), 1994-95

Knowledge of at least one contraceptive method           75.5
Knowledge of at least one traditional method             17.3
Knowledge of the source of at least one modern method    58.8
Knowledge of the source of at least one modern method     4.7
Want a child soon                                        74.1
Want a child soon                                        21.7

Table 10: Selected Demographic characteristics for Pakistani
women younger than 25, PDS 2005

CHARACTERISTICS           PDS 2005                PDS 2003

Percentage Ever
Married Male

15-19 years                2.5                     2.6
20-24 years               23.1                    24.0

Percentage Ever
Married Female

15-19 years               11.7                    13.4
20-24 years               54.9                    56.5

                   ALL                     ALL
                  AREAS   URBAN   RURAL   AREAS   URBAN   RURAL

Percentage
distribution of
births by age
of mother

15-19 years       4.3     2.6     5.1     5.0     3.5     5.6
20-24 years       27.9    27.6    28      27.6    27.1    27.9

Age-specific
Fertility Rates
(ASFRs) per
1000 women

15-19 years       20.3    10.7    26.3    23.7    14.2    29.7
20-24 years       157.6   132.1   173.6   163.1   137.1   178.9

Source: Pakistan Demographic Survey 2005

Table 11. Allocation in PSDP of MoH (in Million Rs.)

                         2001-02   2002-03   2003-04

Proposed                  5,216     8,115     8,880
Actual PSDP Allocation    4,213     3,309     4,373

                                            Planned for
                         Total of 3 Years     2001-11

Proposed                      22,211          95,353
Actual PSDP Allocation        11,895

Source: Progress on Agenda for Health Sector Reforms, March 2004

Table 12. Health Indicators in relation to the Pattern of Health
Expenditure--Comparison with Countries of the Region

                                                PER
                            GHE     CAPITA    CAPITA
              THE AS %     AS %     THE IN    GHE iN
COUNTRY        OF GDP     OF GDP      US$       US$

Bangladesh       3.5       44.2       12         5
Egypt            3.9       48.9       46        22
India            5.1       17.9       24         4
Indonesia        2.4       25.1       16         4
Iran             6.3       43.5       350      152
Pakistan         3.9       24.4       16         4
Sri Lanka        3.6       48.9       30        15
Thailand         3.7       57.1       69        39

Source: Progress on Agenda for Health Sector Reforms, March 2004

Table 13. Public Sector Expenditure on Health
(both Federal and Provincial in Million Rs.)

                        PUBLIC SECTOR HEALTH EXPENDITURE
                            (FEDERAL PLUS PROVINCIAL)

                     DEVELOPMENT     CURRENT        TOTAL       AS %
   FISCAL YEAR       EXPENDITURE   EXPENDITURE   EXPENDITURE   OF GNP

     1995-96            5,741        10,614        16,355       0.8
     1996-97            6,485        11,857        18,342       0.8
     1997-98            6,077        13,587        19,664       0.7
     1998-99            5,492        15,316        20,808       0.7
     1999-00            5,887        16,190        22,077       0.7
     2000-01            5,944        18,337        24,281       0.7
     2001-02            6,688        18,717        25,406       0.7
     2002-03            6,609        22,205        28,814       0.7
2003-04 Allocation      8,500        24,305        32,805       0.8

Source: Progress on Agenda for Health Sector Reforms, March 2004

Table 14. Federal Health PSDP Expenditures
(1995-2003 in Million Rs.)

Fiscal Year    Federal Health PSDP Expenditures

1995-96                      1,852
1996-97                      1,802
1997-98                      1,581
1998-99                      2,024
1999-00                      2,193
2000-01                      1,790
2001-02                      2,669
2002-03                      2,814

Source: Ministry of Health