Pakistan has one of the widest gaps between the desire to plan a pregnancy and the ability to actually do so. More than 6 million unintended pregnancies and 3.8 million unsafe abortions occur there every year, and roughly 9.5 million married women of reproductive age have an unmet need for family planning. The Challenge Initiative (TCI) is a William H. Gates Sr. Institute (WHGI)-led platform that has been working since 2022 with Pakistan’s provincial Departments of Health and Population Welfare Departments to improve access to family planning and reproductive health services in 15 urban districts across Punjab and Sindh.
New research – co-authored by TCI’s Pakistan team and the WHGI’s Victor Imuwahen Igharo and Kojo Lokko and published this month in the Open Access Journal of Contraception – offers evidence that a public-private partnership model can meaningfully close that gap, even when it runs through existing government clinics rather than parallel private-sector infrastructure. Rather than building new clinics or bypassing government systems, TCI trains existing government staff and invests in the facilities already in place: family health days, mobile outreach, integration of family planning into vaccination visits, on-the-job training, and facility upgrades, among other interventions.
To determine impact, the researchers compared contraceptive service data from June 2020 through June 2025 in intervention districts (Rawalpindi in Punjab and Malir in Sindh) against carefully matched control districts (Gujrat and Sukkur) that didn't receive program resources. Using both difference-in-differences and interrupted time-series methods, two complementary ways of isolating a program's real effect from background trends, they found a statistically significant net increase of 3,673 family planning clients per month across the intervention districts. Within Departments of Health specifically, the effect was even larger: 6,100 additional clients per month, with the increase appearing at the point TCI began, rather than a gradual drift.
The results weren't uniformly positive across every department and contraceptive method; some sites saw declines tied to commodity shortages or administrative disruptions unrelated to the program itself, as the study notes. However, the overall pattern of increased indicators held across two different provinces, three different government departments, and two independent analytical methods.
The practical implication is significant for how donors and governments think about scaling family planning access: it suggests that investing in the skills and infrastructure of existing public systems, rather than standing up separate service-delivery channels, can produce durable gains in contraceptive access. The authors point to this as a basis for institutionalizing TCI's approach directly into provincial budgets and workplans, moving it from a donor-funded pilot toward becoming a standard part of how health departments operate.
