Taking cognizance of the high population growth rate as per Census 2017, the Supreme Court of Pakistan took suo moto notice in the subject case set up a task force to prepare a set of recommendations aimed at accelerating the efforts of the Government to reduce Population Growth Rate (PGR), lower Total Fertility Rate (TFR) and increase Contraceptive Prevalence Rate (CPR). The recommendations of apex court were principally approved by the Council of Common Interest in its 40th meeting chaired by the Prime Minister of Pakistan held on 19th November, 2018. One of the recommendations is Population Dynamics in Pakistan to be included in College and University level education. To comply with the recommendation of the apex court Population Welfare Department Population Welfare has involved Higher Education Department for implementation of the recommendation. So for 18 out of 30 public sectors universities has included the population dynamics in various syllabi of the course and is under process in rest of the universities.

There is a growing recognition that religious leaders play an important role in shaping health seeking behavior, especially in conservative, traditional societies like Pakistan, where science, religion, politics and culture intersect. The religious leaders often act as arbiters of morality, ethics and of what is prescribed or proscribed by faith. Their opinions strongly dictate the behavioral norms of their communities, in particular Reproductive, Maternal, Neonatal and Child Health. In environments where Islamic teachings are thought to be prohibitions, religious leaders are able to play an intrinsic role in re-interpreting, authenticating and guiding their congregations according to accurate and foundational Islamic beliefs. Consequently, activities supported by religious leaders and religious institutions have the potential to promote and sustain positive changes in Reproductive, Maternal, Neonatal and Child Health, including changes in behavior related to pregnancy spacing and delaying the first pregnancy. The department has involved religious scholars who as an agent of change will influence decision of common masses in adopting different methods of family planning and reproductive health. Religious Scholars will promote the birth spacing emphasize breast feeding for mother and child health keeping in view the Islamic theories.

Adolescence is the most critical time in life because of risky behavior due to experimental endeavors. Adolescent need information, education, skills and decision making power to function as responsible adult citizens in society. Parents, teachers, community elders are very important to improve the knowledge of adolescents and have great role in promoting ASRH knowledge and behaviors. It is essential to impart knowledge and support in developing necessary skills to make informed decisions about their lives. In the current situations, this critical position and risky adolescence behaviors are creating social barriers because of their lack of knowledge about the ASRH & STIs, therefore it is essential to produce information's to the youth and educate the adolescents to bring attitudinal & behavioral changes amongst them that their hard struggles would carry-out in isolation of the welfare of community that become a prosperous Khyber Pakhtunkhwa and Pakistan.

14 Adolescent Sexual Reproductive Health Centers (ASRH) have been established which are youth friendly facilities with trained staff such as psychologists, social workers and Social Mobilizers (M&F) that provide non-clinical services to adolescents regarding their concerns and needs related to emotional, mental, sexual and reproductive health.

In order to achieve the target of 56% CPR, the Population Welfare Department, Khyber Pakhtunkhwa has planned Family Planning Services in remote areas through task shifting by involving all cadres of health care providers of department of Health and Population Welfare Department. Under this strategy the FP Services will be enhanced, the CPR will be increased alongwith improved mother and child health and reduced stunting and malnutrition.

It has been observed from past experience that the short acting contraceptive methods e.g Oral Contraceptive Pills and Condoms could not make much difference in the CPR. Therefore Population Welfare Department, Khyber Pakhtunkhwa is emphasizing on long acting reversible contraceptives (LARCs) e.g Intrauterine Contraceptive Device (IUCDs including PPICD), injectable and implants, especially post-partum Family Planning (FPEP).The client centered Family Planning (CCFP) training to enhance the counselling skills of the FWA(F&M)s, LHWs, CMWs have also been planned.

Currently FWA(F) and LHWs are giving 2nd and onward doses of injectable contraceptives, Under the task shifting strategy both cadres are trained to administer first dose of injectable contraceptive. To enable safe delivery they will be trained in thorough screening of the clients to exclude risk factors e.g, high blood pressure, history of any cardiac disease or venous Thrombosis in the past. Same is case for training in PPIUD, IUCD insertion by the CMWs, Contraceptive Implant by the Field Technical Officers, Family Welfare Counsellors and LHVs of PWD and DoH. All these procedures would follow alongwith other necessary support to ensure safety of clients as per WHO standards for task shifting.

Objective of the RBM:

1. Result based Planning
2. Result Based Monitoring
3. Result Based Reporting

Result Based Planning:
Aims at orientation and shadowing of officials in:

• Need analysis at FWC level
• Planning of results at FWC, tehsil and district level
• Defining process indicators at Tehsil and FWC level
• Defining Result Indicators at district level

Result Based Monitoring:
Aims at orientation and shadowing of officials in:

• Result Monitoring at district and tehsil level
• Monitoring of results that focuses on gauging efficiency and effectiveness of FP services at client / beneficiaries level
• Process monitoring at FWC level and empowering FWC Incharge to monitor the processes
• Planned and informed monitoring (giving enough time to perform and evaluate accordingly)
• Changing the culture of monitoring to mentoring

Result Based Reporting:
Aims at orientation and shadowing of officials in:

• Reporting on results at district and tehsil level
• Activity reporting at FWC and Tehsil level
• Reporting on internal challenges and how to mitigate these challenges
• Reporting on external risks and mitigating strategies
• Reporting on successes and lessons learnt to learn and reflect as an ongoing process

Thus, the overall objective of RBM is to develop a culture of mutual trust, mentoring and support ensuring efficiency and effectiveness of PWD through behavioral change and capacitated staff.

Inintially the activity started on pilot base in three districts i.e. Mardan, Charsadda and Nowshera in the year October 2014 which was then expanded to rest of the districts of the province. Mr. Hussain Ahmed, DPWO Malakand, Mr. Basit Saeed, Sr. Instructor RTI Peshawar and Mr. Umer Farooq, Dy. Demographer trained the Officers and Officials of the districts with the kind supervision of Mrs. Riffat Shams, Pathfinder consultant.

The reporting & activity system of the RBM activities is based on the following indicators:

1. The FWC staff should plan its PWD activities in line with the total eligible couples of the area and it should be guided well by the district team.
2. Mohalla/ village maps for 3 selected areas are developed by the FWC staff and guided by the district core team. The information about community influential of these villages should be collected by male assistant.
3. Registration information should be used for planning of PWD activities. Thus mapping and work plan should be informed by the registration information.
4. Maps of three villages should be completed by all FWCs and the information reflected on maps should be verified by FWC incharge and Tehsil/ district officials. Once the PWD activites are carried out in the selected 3 villages, three more villages/ mohallas should be selected to work accordingly.
5. A detailed review meeting should be conducted at Tehsil level with the FWC Incharge and analysis of progress should be done to discuss further with the staff and plans for next months should be done in the light of progress reviewed.
6. The district officer should conduct review of Tehsils and tehsil officials should present the progress of their Tehsils and discuss the challenges, strengths, case studies, mobilization strategies for engaging influential and etc.
7. Analysis of information (progress) should be done using different perspective especially average users for condoms and pills, progress made by female and male assistants and FWC Inchrages.
8. One monitoring visit by FWC Incharge should be done once in a week for male and female staff. The FWC Inchrage should make sure that registration information is correct and used for planning of PWD activities at FWC level. Thus a process of informed planning starts.
9. Monitoring of male staff should be done by Tehsil officers and the tehsil officials should meet community influential, male clients to help the male staff learn how to conduct dialogue with males about PW.
10. Jirga meetings by male assistants should be planned once in each week. District/ tehsil staff should attend the Jirga meetings to support the male staff.
11. Targets should be assigned for reaching out the communities instead of contraceptive distribution. The demand for contraceptive will be generated if the districts ensure that the outreach workers of department meet with people; provides counseling and motivation to them.

With the support of JSI international monitoring and supervision software has been developed in year 2020 and is operative in all the settled districts. The software has two parts one is PMIS (Population Management Information System) and an android mobile application tool developed for online Monitoring and Supervision of the field activities. Monthly Data is entered into the PMIS by all the districts which is then consolidated into a provincial report. This report is reviewed and analyzed at the provincial level and necessary feedback is provided to the districts based on their performance.

M&S system (Monitoring and Supervision) is an android mobile application. This system is used by the District and Provincial level monitors and supervisors of the department. The monthly visits are planned by the district and provincial monitors on the system. These visits are then approved on line at the provincial level. The monitors visits the facility as planned and enter their report then and there on the mobile application which is then uploaded in the system and is available for review at the provincial level. The date, time and exact location at the time of entry and uploading is recorded in the system.

Both the tools are fully automated and provide useful information for the senior level management of the department for making evidence based decisions. This innovation has standardized the reporting and has also made the information readily available for proposing any change and making corrective actions.

With the support of JSI, M&E cell has been established at the Directorate General of Population Welfare Department. The cell is fully furnished and equipped with latest HD Audio Visual conferencing system. The conference room has a sitting capacity of 20-25 persons and is used for internal and external meetings. During covid 19 the system has been extensively used for virtual meetings with the District Population welfare offices, Ministry of National Health Services and Regulation and with International NGOs and partners from time to time. Apart from that the M&E cell also has 4 working stations with latest desktop computers and internet connection which is used by the IT and M&E staff.

The Narrative

The provincial narrative aims at regulating population growth to ensure wellbeing, prosperity, safety and security which is the common aspiration of people of the province. The attainment of this imperative goal is possible through three interlinked principles:

• Rights — The first principle recognizes that all citizens of the province have fundamental rights, which are enshrined in all religious teachings, the Constitution of Pakistan and the international covenants (ICPD, FP2020, SDGs) to which Pakistan is a signatory. This includes the right to adequate shelter, nutrition, health and family planning, education, employment opportunities and gainful livelihoods to improve the quality of life.

   

• Responsibilities — The second principle is the recognition that, to attain these rights, individuals, parents as well as the province have distinct responsibilities to fulfill. The parents ought to act responsibly (responsible parenthood) and have the number of children they can provide with the basic rights, e.g., nutrition, health, and good upbringing, while the province remains responsible for providing necessary services and resources, such as family planning and health services, quality education, proper housing, and job opportunities.

   

• "Tawazun" — The third principle recognizes the need to strike a balance, or tawazun, in all aspects, especially between rights and responsibilities. This implies a Tawazan between population growth and available resources. "Tawazun" is intrinsic in Nature and commanded in Islam and other faiths as a prerequisite for peace and well-being.

   

Sustainable population growth means growth in which this tawazun is maintained. It must prevail, at the macro level, between essential human goals and population numbers; the numbers and quality of citizens; natural resources and the people they sustain. At the micro level, tawazun must be attained between the births of children and their mother's capacity to recuperate and breastfeed them; between the size of families and their capacity to ensure the rights of each member. All eminent religious scholars world over have endorsed birth spacing as one way to ensure balanced family size.

While family size remains a private choice, separate from the public domain, parents' right to have as many children as they desire must be balanced with their responsibility to ensure that each child is brought up under the care of a healthy mother. Certainly, family planning and birth spacing should be driven by informed choice and free will, and no coercion. But the province is responsible for fulfilling all citizens' right to the information and services they need to make and act on informed choices.

The province and Society must enhance awareness of health benefits of family planning, especially the wisdom and concern for maternal and child health underlying the Quranic injunction that mothers breastfeed their children for two years. In particular, pesh imams (prayer-leaders) in mosques across the country and the senior-most religious scholars must come forward in support of balanced family size to help forge an authentic national consensus.

The Province must provide free and easy access to new-married couples, first-time parents and other married couples to high quality counselling, complete information on contraceptive options, related benefits and risks, and wide range of effective modern contraceptives and follow-up services. The province is responsible for imparting educational content to sensitize youth about implications and advantages of planned families.

As per the CC1 recommendations, the province must act on an emergency footing for couples who want to practice family planning but do not have access, and for others who are unsure or still planning their families, as well as the millions of married women who have had to resort to unsafe abortions.

Under the 18th Constitutional Amendment, the province is responsible for improving and expanding comprehensive health services and doing so collectively with the private sector and civil society organizations. In particular, family planning must be offered as a core element of maternal and child care to seize the opportunities, currently being missed to help attain tawazun. As mandated by CCI, family planning counselling and modern contraceptives should be made available at all public and private sector health care facilities, in addition to centers specifically devoted to provide family planning services.

In conclusion, to secure and sustain balanced population growth by actively seeking behavioral change in target groups, is a responsibility shared by every citizen of the province of Khyber Palchtunkhwa.

The capacity building is an important intervention for the employees of the programme and non-programme personnel. After the devolution under 18th amendment the Population Welfare Department Khyber Pakhtunkhwa remained without any institutional setup for non-technical and administrative tier training for its staff.

The need was felt to provide training to staff of Population Welfare as well as the line departments in different disciplines pertinent to their official responsibilities and achieving targets related to Population Welfare Department. To meet this need Population Welfare Training Institute has been established at Peshawar under ADP Scheme.

Objectives of Population Welfare Training Institute:

• To implement effective in-service training programs based on the training needs of non-technical staff.
• To arrange pre-service training of newly recruited non-technical field employees.
• To enable the provision of innovative techniques by building capacity of non-technical staff at field level.
• To establish responsibility of control through capacity building in the employees in term of field activities.
• To bring attitudinal changes through capacity building amongst the Elected Representatives, community based groups, schools and colleges teachers / lecturers, religious leaders, influential and NGOs.

Advocacy and Communication is One of the Eight areas under the CCI recommendations, duly endorsed by the Supreme Court of Pakistan. Consequently, a new Narrative based on Rights Responsibilities and Tawazun was approved by the Provincial Population Task Force (PPTF) under the Chairmanship of Hon'ble Chief Minister Khyber Pakhtunkhwa.

Although success has been made in raising awareness about Family Planning, but wide gap still exists with respect to practice and knowledge. 97% people know about at least one method of contraceptives, however, only 31% married couples are using contraceptives for spacing or limiting their families. Similarly, Total Fertility Rate is high at 4 children per woman, wherein one pregnancy was unwanted, meaning the couple didn't want the fourth child, however, due to various reasons, they didn't use contraceptives for limiting their family size.

Furthermore, promoting FP/RH through Electronic Media is part of an approved ADP scheme "Innovative Scheme for Promotion of Population Welfare Programme" as well as the Communication Strategy developed in the light of CCI recommendations. The target audience will be married couples of reproductive age and also include Newly married couples, Young people soon to get married, Family Planning Service providers, married couple with unmet need as well as influencers like Husbands, Family Elders, decision makers and Religious Leaders, etc.