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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section Two - Nine AUICK Associate City (AAC) Reports

12. Faisalabad, Pakistan


Historical Background of Faisalabad

District Profile

Discussion / Analysis of Responses of Health / City District Government Administrators, Faisalabad


Dr. Masooma Sardar 

Deputy District Officer, Health, City District Government Faisalabad (Participant of Second 2007 Workshop / AUICK Liaison Officer) 
Dr. Mian Zahid Malik 
District Tuberculosis Control Officer, Faisalabad (Participant of Second 2008 Workshop)

Faisalabad Map

Historical Background of Faisalabad

The city was founded in 1892 by British Sir James Lyall (Lieutenant Governor of Punjab (1887-1892). So its original name was Lyallpur. The city centre of Lyallpur was designed by Capt. D Poham Young C.I.E to model the British Flag (Union Jack) with a large Clock tower in the center and eight bazaars (markets) around the clock tower. In 1977, the name of the city was changed to Faisalabad in honor of the late King Faisal of Saudi Arabia. Faisalabad is the third largest City in Pakistan. It is located in Punjab Province. 

District Profile

- Tehsils 06 
- District Headquarter Hospital (Teaching Hospital) 01 
- Allied Hospital (Teaching Hospital) 01 
- Private Hospitals 30 
- Tehsil Headquarter Hospital 05 
- Rural Health’s Centers 12 
- Basic Health Centers 168 
- Mother Child Health Centers (MCH) 05 
- Government Dispensaries (GDs) 33 

Up to Basic Health Units, indoor beds are available; while in MCH centers and GDs, there are no beds are present. 

Total Population of District Faisalabad 7,310,692 
Urban Population 2,873,145 
Rural Population 4,437,547 
Total Covered Population by Lady Health Workers (LHWs) 2,719,448 (37.19%) 
Average Total Covered Population per LHW (Urban + Rural) 1,250 
Covered Urban Population by LHWs 292,774 (10.19%) 
Average Covered Urban Population per LHW 1,450 
Covered Rural Population per LHW 2,426,674 (54.68%) 
Average Covered Rural Population per LHW 1,035 
No. of LHWs working in Faisalabad 2,542 
No. of LHWs working in Urban Slum 202 
No. of LHWs working in Rural area 2,340 
Population per Doctor 1,183 (Pakistan) 
Population per Midwife 6,203 (Pakistan) 
Population per Lady Health Visitor (LHV) 16,845 (Pakistan)

Faisalabad RH Services DataFaisalabad RH Services Data (Continued)Faisalabad Objective RH Services Data (Continued)Faisalabad Objective RH Services Data (Continued)

In the 1970s, very limited Mother Child Health (MCH) services were available both in the public and private sectors. The Family Planning Association of Pakistan (FPAP) was the only NGO working in MCH services. There was only a District Headquarter Hospital with just one Woman Medical Officer (WMO). Its total capacity was 120 beds, out of which few were for gynecology / obstetrics. In the private sector, the National Hospital and Mian Muhammad Trust Hospital had one gynecologist each. There were few lady doctors running private clinics. In government dispensaries, Lady Health Visitors (LHVs) were appointed. 

While for the Extended Program on Immunization (EPI), some of these dispensaries were declared as points for immunization, only BCG and Tetanus Toxoid (TT) vaccines were given (BCG for children and TT for Pregnant Ladies). Immunizations were administered by technicians appointed at dispensaries. 

In 1974 the Punjab Medical College was established, and this was the turning point. 

In the 1980s, the health sector saw much progress, with the establishment of the Punjab Medical College. More health services, including MCH, were available to the community. In December 1982, a pilot project for immunization against six diseases (tuberculosis, poliomyelitis, pertuses (whooping cough), diphtheria, tetanus, and measles) was launched. Doctors and paramedical staff were trained in this. In 1983, vaccinators were appointed. The new private hospital and private clinics provided better MCH services. More lady health visitors were employed, and the FPAP became more effective and expanded its services to different areas through its centers. 

A Health Management Information System (HMIS) was introduced in the government sector. All staff in the Health Department were trained on this. 

Unfortunately, no data was previously available either from the government or private sectors. It is still the weakest link, but has been improving since the 1980s. 

In the 1990s, more private hospitals /clinics were seen. The Allied and District Headquarter Hospitals (Both teaching hospitals) improved and expanded their services in the MCH sector with more expertise. 

The Lady Health Workers’ Program started in 1996. They were trained to give services regarding family planning and primary health care. However, until 2009 they were giving services only to 6% of the total urban population, because lady health workers were recruited until 1998. Then, this was banned and the whole program was shifted to the rural area. 

In the decade after 2000, more stress and importance were given to MCH services. The new terminology of Reproductive Health (RH) was introduced, with all of its nine components. Lady health workers were again trained on the new HMIS and RH. They were trained in Family Planning (FP), especially in administrating contraceptive injections themselves to the FP clients, thus providing this service at the door step. Services were also provided in the Optimal Birth Spacing Initiative (OBSI) / interval, new born care, child health, diarrhea and respiratory tract infections in infants and children, nutrition and safe motherhood, etc. 

New NGOs like the Marie Stopes Society, Green Star and Key Social Marketing came into the market. The Millennium Development Goals (MDGs) were set and the government started giving emphasis on RH services to achieve the MDGs by 2015. New LHWs were recruited in 2009 in the urban slum area, so their coverage rose to about 11% of the total urban population, to expand/extend services/coverage. 

The combo vaccine was introduced, adding the vaccine against hepatitis B. Thus now immunization was against seven diseases. In 2008-9 the combo vaccine again was changed to include the pentavalent vaccine, which has an HIB vaccine against meningitis. The booster dose of measles was also introduced. Now immunization was against eight diseases. Multiple refresher training courses for medical/paramedical staff/vaccinators were arranged, especially in FP, EPI and RH services. The community midwife cadre was introduced under the Maternal Neonatal Child Health (MNCH) Programme. 

Camps for contraceptive surgeries are arranged, and there are more private clinics/hospitals. One maternity hospital was established with the help of the Red Crescent. Two private medical colleges were established. 

In 2007, after attending the AUICK Workshop in Kobe, Japan on maternal and child health care in natural disaster management, it was realized that data collection in Faisalabad is poor. From then onwards, serious efforts are underway regarding data collection, its verification quality and so on. Therefore, again in 2009 the HMIS was revised and re-named the District Health Information System. It is more comprehensive and organized, and the whole staff are trained. But still it needs much improvement regarding collection and authenticity. From the private NGO sector, there is still no data, or very scarcely collected data. 

It is still the weakest link, as much data is missing and hard to get from the public / private / NGO sectors. Even the data which is collected needs to be verified, and sometimes raises questions regarding authenticity. However, steps are being taken to improve/ rectify this issue. In short, in this decade the City of Faisalabad, though facing the problem of urbanization, has relatively improved RH services. Health indicators are improving. 

RH services/conditions are very low and given moderate to low priority, and they need more attention, but due to other competing demands this area is being neglected. Actually, most of the people on administrative and political sides are not aware of the importance of RH. Great efforts are required to create this awareness. Thus, support is needed from all sectors. Similarly, the resources available for RH services are very/woefully deficient, and special attention is needed to increase resources. The government alone cannot improve RH services. The involvement of the community/NGOs/the private sector is needed. It should be a joint effort. 

In 2000, 2005 and 2010, 31%, 34% and 40%, respectively, of the total population were below the poverty line (Pakistan Economic Survey). For 2025, this cannot be predicted, as it is all dependent on circumstances. It can either deteriorate or improve. No separate RH services or RH Budget is available to the migrants and other populations of the city. 

In the city, about 35 to 40% of slum dwellers are benefiting from FP Services. (The Contraceptive Prevalence Rate (CPR) in the urban area varies from 39% to 42%.) The national CPR is 30% (Population Reference Bureau 2009 Pakistan Economic Survey). No special programs to increase RH services to slum dwellers are available, and no special health or social programs to deal with the new floating population are present in the city. 

RH services are given moderate to low priority because it is felt that this issue is not taken so seriously. The impact RH can have on the development of the nation is not/less known to people at all levels, right from the government to the community. Unless the benefits/importance (both short and long term) of RH services as a whole are known to all levels, full administrative and political support/commitment cannot be attained. The resources available for RH services are definitely deficient in human, financial, logistical and infrastructural terms; i.e. in every aspect. Detailed micro planning is required for this purpose, highlighting importance and justification. 

No special programs to increase RH services to slum dwellers are present, except the Lady Health Workers (LHWs) Programme for Family Planning and Primary Health Care (FP and PHC). However, it covers only 10% of the total urban population. The coverage of the LHW program should be increased in the urban slum area, as these LHWs provide both RH services and PHC services with special emphasis on RH services. LHWs are only there to bridge the gap between the community and the health care facilities. They provide treatment for minor ailments, identify risk factors regarding RH components, and refer the community to health care facilities. Each LHW is supposed to be a resident of the area where she will work. Academic qualification is preferably 10th standard, but if 10th standard female is not available then 8th standard female can be selected, and she is preferably married and aged from 18 to 45 years. In the urban area, she is supposed to work for and register a population between 1,200 and 1,500 people in her catchment area. In fact, no such data is available for the estimated size of the city’s new immigrant population (the new floating population), from any department of the City District Government. Every year, however, urbanization is increasing, because Faisalabad is an industrial city. The annual growth rate (AGR) is 1.9 % for Faisalabad (the national AGR is 2.1 %). 

It can only be guessed/estimated that the percentage of the urban population will increase in coming years. Presently, it is 39.3% of the total population. Every year it is increasing. So, in the light of this, it is evident that RH services will not be sufficient for these projected populations, if some remedial steps are not taken now. 

Discussion / Analysis of Responses of Health / City District Government Administrators, Faisalabad

Names / Designations of City District Government Administrators:

1. Mr. Rana Zahid Tauseef, Ex District Nazim Faisalabad 
2. Mr. Mian Amjad Yaseen, Ex Deputy District Nazim Faisalabad 

Names / Designations of Health Administrators: 

1. Dr. Azhar Waheed, District Officer Health (I) Faisalabad 
2. Dr. Captain (Retd) Mohammad Akram, District Officer Health III (Urban City Area) 
3. Mst. Tahira Tanir, Assistant District Coordinator, Lady Health Programme Faisalabad 
4. Farrukh Bashir, Project Director, Family Planning Association Faisalabad 
5. Dr. Shazia, District Coordinator, Maternal, Neonatal, Child Health (MNCH) Programme 

RH Services: 

1. Family Planning 
2. Maternal Health 
3. Child Health 
4. STIs (Sexually Transmitted Infections) 
5. Infertility 
6. Post Menopausal Problems 
7. Cancer of Breast and Reproductive System 
8. Male Reproductive System Problems 
9. Reproductive Health Problems in Adolescents 


1. What are considered the most important RH issues and conditions? 

List respondent’s views to probe: 

a) HIV / AIDS 
b) Sexually Transmitted Diseases (STDs) 
c) Family planning for health of mothers 
d) Family planning for / against population growth 
e) Infertility 
f) Safe motherhood 

In the opinion of City District Government administrators, they are not health professionals, so they do not know what RH is. For them, family planning for/against population growth is the most important RH issue. Family planning is the key for the better status of people both socially and economically. Excessive population growth can badly affect all socio-economic factors/indicators. 

In the opinion of health administrators, family planning for the health of mothers, for/against population growth and for safe motherhood are the most important RH issues, because they include almost all aspects of RH. Maternal health depends on the spacing between two pregnancies, family planning etc. It also casts its shadow on the socio-economic status, mental stress and physical health condition of family members/culture/society/population/the nation. Increasing population growth is just like a bomb which devastates all socio-economic factors. All social/financial/service provision/health indicators are dependent on the size of population and population growth rate. 

2. Overall, how is the level of the city’s reproductive health condition? 

a) Excellent 
b) Very good but could be improved 
c) Needs more improvement 
d) Seriously low and needs much improvement. 

In the opinion of City District Government administrators, RH conditions are very low due to many factors, and there is much need for attention and improvements. 

In the opinion of health administrators, RH conditions are good in the city, but there is a need to improve RH conditions regarding infrastructure, resources, logistics, and sensitization of the masses, the administration, politicians and notables, both in the public and the private sector. So, special efforts are required. 

3. Overall what priority does the city give to RH services? 

a) The Very highest 
b) High 
c) Moderate: the problem is not serious 
d) Low: the problem is basically solved and procedures are routine 
e) Low: the problem is still very serious but due to other competing demands 
f) Low: due to lack of political support or commitment

In the opinion of City District Government administrators, RH services are given moderate to low priority and they need more attention, but due to other competing demands, this area is being neglected. Actually, most of the people on administrative and political sides are not aware of the importance of RH. Great efforts are required to create awareness. Thus, support is needed from all sectors. 

In the opinion of health administrators, RH services are given moderate to low priority because it is felt that this issue is not taken so seriously. The impact RH can have on development of the nation is not/less known to the people at all levels, right from the government to the community. Unless the benefits/importance (both short and long term) of RH Services as a whole are known at all levels, full administrative and political support/commitment cannot be attained. 

4. Overall how do you feel about the resources available for RH services? 

a) Fully adequate 
b) Quite good 
c) Somewhat deficient 
d) Woefully deficient 

In the opinion of City District Government administrators, the resources available for RH services are very/woefully deficient, and special attention is needed to increase resources. 

In the opinion of health administrators, the resources available for RH services are definitely deficient in terms of human, financial, logistical, infrastructural, i.e. in every aspect. Detailed micro planning is required for this purpose, highlighting importance and justification. 

5. What are specific needs of the city to improve its RH services? 

a) None: services are now quite adequate, including the private sector services. 

b) Less than adequate service, more is needed in: 
b1) Funds 
b2) Personnel 
b3) Equipment 
b4) Facilities such as examination rooms 
b5) Political support 
b6) Others (please describe): 

c) Far Less than adequate service, more is needed in: 
b1) Funds 
b2) Personnel 
b3) Equipment 
b4) Facilities such as examination rooms 
b5) Political support 
b6) Others (please describe) 

In the opinion of City District Government administrators, all the points (from b1 to b6) require attention. The government alone cannot improve RH Services. The involvement of the community/ NGOs/the private sector is needed. It should be a joint effort. 

In the opinion of health administrators, more funds are required for RH Services. In fact, budget allocation for the health sector is quite low (3.5% of the total budget). No specific budget is allocated for RH. 

There is a shortage of staff for RH services (both medical and paramedical). The number of posts should be increased, in addition to the filling of vacant posts. More equipment is needed for the establishment of RH centres. Unless our political figures show their full commitment and support and take interest wholeheartedly, RH services cannot be improved, as they are policy makers and budget allocation falls into their jurisdiction. Both private and NGO sectors should be taken on board, and private/public/NGO partnership models should be adopted, as RH services alone cannot be improved singly. 

6. What is the size of the cities slum or below poverty level ($2 per day) population? 

In 2000 (in actual number or % of total population): 
2005: and 
2010: 
Any future projection: 2010 or 2025? 

In the opinion of City District Government administrators and health administrators, in 2000, this was 31% of the total population; in 2005, 34% of the total population; and in 2010, 40% of the total population. A future projection cannot be made, as it is dependent on circumstances. It can either deteriorate or improve. 

7. To what extent are city RH/ Family Planning (FP) services available to the slum dwellers? Are any factors impeding this availability? How could it be increased? (Please provide a rough percentage estimate and then discuss conditions)

In the opinion of City District Government administrators
a) According to the data available, only about 25 to 30% slum dwellers are using FP Services from both private and public sectors. 
b) There are many factors which impede this availability; e.g. insufficient funds, human resources, logistics, infrastructure, and awareness. 
c) The availability of FP services can be increased by resolving the issues mentioned above. 

In the opinion of health administrators
a) In the city, about 35 to 40% slum dwellers are benefiting from FP services. (The contraceptive prevalence rate (CPR) in the urban area varies from 39 to 42%.) So, a lot has to be done. 
b) The factors to overcome to improve this availability are multiple, e.g. poverty levels, lacks of funds, human resources and training of existing human resources, logistics, infrastructure, full administrative and political support and commitment, awareness amongst the masses, private/public/NGO partnership models etc. 
c) The availability of FP Services can be increased/improved by addressing the abovementioned factors. 

8. Are there special programs to increase RH services to slum dwellers? Is so, please describe them, especially in terms of the following: 

a) Staff size and categories designated (e.g. MDs, nurses, midwives etc.) 
b) special features 
c) size of budget 

In the opinion of City District Government administrators, no special programs to increase RH services to slum dwellers are available. There is no specific staff size, as out of the total available staff, some are deputed duties in gynae wards / out patient departments. The budget / logistics are provided by the city / provincial governments. 

In the opinion of health administrators, there are no special programs to increase RH services to slum dwellers at present, except the Lady Health Workers (LHWs) Programme for Family Planning and Primary Health Care (FP & PHC). But it covers only 10% of the total urban population. 

Total population of Faisalabad District: 7310692
Urban population: 2873145
Rural Population: 4437547 
Urban population covered by LHWs: 293610 
No. of LHWs working in urban slums: 202 

These LHWs provide both RH and PHC services with special emphasis on RH services. LHWs are only there to bridge the gap between the community and the health care facilities. They provide treatment for minor ailments, identify risk factors regarding RH components, and refer the community to health care facilities. 

Budget / logistics are provided by the federal / national governments, and the city / provincial governments have no role in their provision. They are only the implementing agencies. 

9. What is the estimated size of the city’s new immigrant (the new floating population)? 

In the opinion of City District Government administrators and health administrators, as mentioned above, unfortunately no such data is available for the estimated size of the city’s new immigrant population (the new floating population), from any department of the City District Government. But, every year, urbanization is increasing because Faisalabad is an industrial city, with an annual growth rate at 1.9%, and there are more job opportunities. Existing RH services will not be sufficient for these projected populations. It can only be guessed/estimated that the percentage of the urban population will increase in coming years. Presently it is at 39.3% of the total population. Every year it is increasing. So, in the light of this, it is evident that RH services will not be sufficient for these projected populations, if some remedial steps are not taken now. 

10. To what extent are city RH services regularly available to the migrants? Does this represent a problem for the city? Are there any special health and social programs to deal with this new floating population? What kinds of program are necessary? 

In the opinion of City District Government administrators, no separate RH services are available to the migrants. They avail the present RH Services. No special health and social programs to deal with this new floating population are present in the city. The growing population is representing a problem for the city in every field; health and others. New programs are necessary to improve RH Services. All departments, and private and NGO sectors, need to join hands to work on this. 

In the opinion of health administrators, no special RH Service delivery centres are made for the migrants. They avail the existing RH Services. The increasing population size/urbanization in the city is posing problems regarding issues related to RH services, sanitation, hygienic conditions, safe drinking water, housing, employment, socio-economic/crime burden, environmental pollution, etc. 

New programs are necessary to improve RH services, in addition to the expansion of existing LHW programmes. For this purpose, MNCH programmes should be launched in the city. New RH care centres in the existing health system should be established, along with the involvement of the private/NGO sectors, with a focus on RH services. 

11. What is the breakdown of the total budget for RH services in terms of the following? 

i) Percentage of costs covered by city government 
ii) Percentage of costs covered by national government
iii) Percentage of costs covered by other sources (e.g. donors etc.)? 

In the opinion of City District Government administrators and health administrators, it is a pity that no specific budget is allocated for RH services. A lump sum budget is allocated for the health sector, which comes to about 3-4% (3.5% / 1.19 billion rupees for the current fiscal year) of the total budget of the City District Government. As no specific grant/fund/budget is fixed for RH services, it is up to the Health Department to decide how much it spends on RH services. 

Budget is allocated by the national government to the provincial government which allocates to the city government. No donors/other sources contribute in this budget except at the national/provincial levels. 

It is to be noted that the number of abortions is highly under reported, as many are carried out informally, and so go unreported. 

In fact, in Pakistan there is a National Finance Commission which allocates funds to all provinces from the Federal Revenue, so that provinces can prepare their budget. Provinces, in turn, give funds to the districts. Districts also collect their own revenues and pool them along with the budget received from the provinces. Demand is transmitted from the concerned department / sectors. However, actual allocation does not meet the demand. About 72% of the total health budget is spent on salaries. During the last decade the percentage of the total health budget has increased. (Reference: www.spu.org.pk Strategic Operation Plan (SOP) Health, Chapter 9). 

Note: The exact data is still not available. The data shown below is for 6% of the total urban population for 2000-2005, and 11% for 2010. Sources are the HMIS, DHIS, LHWs MIS, Statistical Bureau, FPAP, and Ministry of Population. No data is available from private hospitals / clinics / maternity homes, while teaching hospitals give scanty data. Some of the data raises concern regarding its quality. This is the most major issue of the City Health Department.

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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