Addressing Provider Bias in Pakistan
By: Madiha Latif
Tags: Hcd, Bias, Contraception, Youth, Pakistan

Pathfinder International is an organization that is committed to removing barriers to critical sexual and reproductive health services in developing countries, with the objective of enabling millions of women, men, and young people to make their own choices regarding their health, paving the way for a secured future. Applying a holistic intersectional lens, Pathfinder looks towards developing effective solutions that address social, economic and systemic barriers to access of health services, with a focus on marginalized groups.

Pakistan is a country with a burgeoning youth cohort, currently standing a 64% of total population. The past few years have demonstrated a stagnant contraceptive rate, despite efforts of government and health departments to encourage uptake of contraception. If all variables remain constant, with a young population, high fertility rate and low use of contraception, Pakistan’s population will grow exponentially over the next 30 years.

Pakistan Population Forecast

[Elaboration of data by United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2019 Revision (Medium-fertility variant)]

The chart above shows the increasing population over the next 30 years, if fertility rates remain the same. This is worrisome as consistent high numbers of birth would exacerbate current issues of climate change, limited basic resources such as food water and shelter, health and education resources, as well as poverty, amongst others. If we look at population growth under health pandemics such as COVID-19, we can see that densely populated cities such as Karachi, are showing high infection, reproduction and transmission rates, with pressures building on health resources.

With limited access to information, health care providers tend to be the point of information for many young people. A recent survey undertaken by Pathfinder Pakistan demonstrated that provider experience does, in fact, shape the decision an individual makes for their health. Of 200 respondents, between the ages of 15–29, 63% mentioned that their provider experience completely shaped their decision, while only 5.5% mentioned that it did not.

Respondents were also asked where contraceptive was accessed from with the options of choosing facilities, pharmacies and other. It was found that 86% of respondents accessed contraception from facilities. 20% of respondents mentioned they accessed contraception from pharmacies, because it was private, more convenient, and they did not have to answer any questions. Given social context, it could be safe to assume that more likely than not, only married young people are seeking out family planning information from providers, while those that were not, possibly felt safer accessing products from pharmacies due to fear of bias against them.

Pathfinder, BERI, Camber Collective and YLabs began exploring various barriers to uptake of adolescent family planning services and identified provider bias as one of the main forces of determining choices. We learnt during our research phase that the social environment that the provider grows and lives in contributes enormously to their inherent attitudes and perceptions, even while operating as health care provider. For instance, in Pakistan, pre-marital sexual activity is considered taboo, and thus, providers operate within that consciousness, thereby unwilling, or ignoring, the need for reproductive health services for young unmarried people. There is a lot of pressure on young couples to have children right after marriage. Providers fear stigma and backlash from their communities, families, and social networks, and thus choose not to go against the grain by promoting birth planning/spacing of young couples.

These inherent biases may not always stem from fear (normative), but from personal conviction and beliefs as well

Pathfinder in collaboration with Ylabs (design partner) applied a human centred design #HCD approach to develop solutions which address provider bias through the Beyond Bias intervention.

The Beyond Bias intervention, referred to as ‘Nai Umang’ in Pakistan, takes providers on a journey of self-realization [Summit], peer support [Digital Connect], and motivation [ Reward] which we believe will ultimately lead to behavior change.

Provider attitude plays a key role in the provision of quality care services, which is what the intervention is addressing. Nai Umang’s strategy pushes providers to reflect on their own biased attitudes and behaviors, and encourages them to see how these biases affect consumer choice and behavior. The intervention allows them to see how this leads to larger social issues, and then supports providers and continually guide them to create safe environments for young people to make choices about their health and bodies. It is a holistic approach to a complex issue, and focuses on self-realization without shaming the participants, while taking into consideration a provider’s environment and development as well — a step often missed in larger health programming. The model is being tested for its effectiveness and feasibility with a subset of providers in the Greenstar Social Marketing network [Karachi] with results likely to be disseminated next year.

Beyond Bias is a multidisciplinary project which is led by Pathfinder International in collaboration with YLabs, Camber Collective and BERI with the support of Bill and Melinda Gates Foundation. The project is being implemented in Tanzania, Burkina Faso and Pakistan. In Tanzania and Burkina Faso, Pathfinder is working with the respective Ministries of Health while in Pakistan we are implementing with Greenstar Social Marketing.

While it may be early, we have seen some significant changes in provider behavior and approach and have also identified areas where work still needs to be done. What is clear, however, is that the future of reproductive health programming has to include continual behavior change engagement with providers to effectuate real change.