There are many ways to expand access beyond static clinics and, over the past 30 years, many of them have been tried in Pakistan. The training of traditional birth attendants, or dais, has been tried on many occasions in South Asia, but their low social status prevents them from being plausible agents of social change, and their impact on family planning has been negligible.

In the long term, of course, integration of the health and family planning outreach programs is both desirable and inevitable. Since it lost direct responsibility for family planning in the mid-1960s, the Ministry of Health has made limited effort to provide contraceptive advice and supplies as part of its overall health service due to loss of mandate. One of the most encouraging results to emerge from the 1996–1997 Pakistan Fertility and Family Planning Survey is that the Ministry of Health workers are actively promoting contraception. It is to be hoped that an era of closer collaboration between the two ministries has begun.

Under the proposed MNCH program, efforts would be made to ensure that preferably all (DHQ/THQ/RHC/BHU) health facilities are providing maximum range of family planning services for optimal birth spacing. All logistics and training needs would be met from the Program in close collaboration with the MOPW.

Expansion of Comprehensive Family Planning Services to all Health Facilities

Expansion of Family Planning Services to include all Health facilities requires the availability of contraceptives at health facilities. In order to provide enough stock of contraceptive at all health facilities the capacity of the existing system to distribute logistics needs to be enhanced, for this purpose the districts require transportation capability. In case of large districts the district government may be asked to provide funds to construct a warehouse for contraceptives.

Contraceptives shall be procured from the Ministry of Population Welfare by the EDO (H) according to estimated need calculated on the basis of usage, staff at health facilities and previous patterns of consumption. This provision shall be expanded to the CMWs as and when they start work in the field. However, I case there is still gaps of shortfall in the supply from the MOPW, a small amount is placed in the FEC component to keep the option open for other donors to pool in their resources for procurement of contraceptives if the need arises over the program life.

Surgical Contraceptive Services:

The MOPW designates the facilities providing contraceptive services and staffed by MOPW staff as RHS-A centres. At present this facility is available in all DHQ hospitals and the newly upgraded districts will also be covered through the MOPW by provision of centres at the new DHQ hospitals. The MOPW is implementing a program to construct RHS-A centres at THQ hospitals; the current allocation is 62 in Punjab, 9 in NWFP, and 34 THQs in Sindh. The staff for these centres will be provided by the MOPW and the performance of these centres will be closely monitored by the District MNCH Cell. The provision of reimbursement and referral fee will be undertaken through the MOPW. The EDO (H) will receive a monthly report on the number of referrals to these facilities.

Family Welfare Centers

In the first phase of the program all the BHUs and RHCs shall be declared as Family Welfare Centres and will provide contraceptive counselling and methods to all clients except for surgical contraception. However this can be reviewed at the end of Phase I of the project in collaboration with the MOPW and if required the provision of converting the RHCs to RHS-A centers can be adopted. At the BHU/RHC the main issue is availability of a female health care provider to enable provision of these services to females. The added benefit of utilizing these facilities is the opportunity to counsel the eligible males attending the health facility to use contraception. The issue of availability of LHVs at all health facilities is already being addressed in the strategy of providing EmONC services through provision of allowance in addition to her salary (from the regular provincial health department budget) for LHVs to work in rural areas.

The EDO (H) will work closely with the DPWO to assure the availability of FP services at all health facilities.

Collaboration with Ministry of Population Welfare

The MOPW has a role to play in the FP strategy and close collaboration with MOPW will be sought. At the National Level MOPW will be involved in the policy decisions and the issue of pricing of contraceptives will be discussed and solved in close cooperation with MOPW.

There is a supply of contraceptives procured by MOPW and a share for the BHUs and RHCs designated as FWCs will be sought from the MOPW. The EDO(H) shall prepare annual plans outlining the requirement of contraceptives and submit them to MOPW for supply. A copy of the same plans shall be sent to the Provincial MNCH Cell which shall monitor the availability of supplies at the district level and if required shall take up the matter with the MOPW. The main issue in the provision of these supplies is submission of request for replenishment of the contraceptives on form LR-6 to the DPWO/Provincial Population Welfare Offices along with the consumption report/sale proceeds. The EDO (H) will maintain an account where the sale proceeds from all the contraceptives shall be deposited and as per agreed criteria 50% of the total amount shall be allocated for management of side effects due to contraceptives and this amount shall be made available to the MS DHQ hospital who will utilize it and submit details of the expenditure and report to the EDO(H). The other 50% of these proceeds will be utilized to identified health facilities providing the best (Reproductive Health) MCH services in the district and depending on the availability of funds 4-5 health facilities shall be disbursed the performance bonus.
 
A regular biannual meeting of the technical staff of both ministries shall be arranged by the Program Director MNCH at the National Level to discuss technical matters. The same meeting shall be replicated at Provincial level. At the district level the DPWO shall be involved in the Implementation of the program as part of the MNCH Cell and therefore it is assumed that the meetings shall be much more frequent.