Background Pakistan’s fertility rate remains among the highest in South Asia, while its progress toward FP2030 goals has been slow. Poor urban populations, which comprise nearly a third of the country’s population, are often missed by conventional health and family planning service delivery systems. The Akhter Hameed Khan Foundation, with funding from the Punjab government, had demonstrated a community outreach model where family planning access was increased for 278,000 population. The current paper describes its scale up to expand coverage to an additional 800,000 population, through community outreach by local women to adapt to the local context and technology to ensure near 100% coverage, enhance the quality of monitoring and lower the costs.

Intervention This digitally monitored, community-led outreach model (“Aapi”) was scaled across 23 urban and peri-urban union councils of Rawalpindi District between November 2022 and December 2024. Locally recruited female outreach workers (Aapis) conducted household mapping and counseling, provided short-term FP methods, and referred clients for long-acting methods. Real-time dashboards, GPS verification, and automated data checks enabled continuous supervision and adaptive management.

Implementation Results The program registered nearly 100,000 married women of reproductive age, achieving near-universal coverage in the intervention area. Contraceptive prevalence rose from 36% to 45% within two years, and 37% of short-term users adopted long-acting methods. Average implementation cost was PKR 1,981 (US$7.10) per user - less than half that of comparable national FP outreach programs. Digital monitoring helped improve data completeness, worker accountability, and program efficiency.

Lessons Learned Embedding digitally supported outreach workers that are from the community in urban neighborhoods can achieve universal FP coverage at low cost. Key enabling factors included local recruitment, simplified digital tools (including digital automation), frequent feedback loops, and flexible supervision. Challenges included staff attrition and sustainability of incentive mechanisms. The Aapi model describes a feasible, scalable approach for improving FP access and accountability among underserved urban populations in Pakistan and similar low- and middle-income country (LMIC) settings.

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study protocol, including the verbal informed consent by MWRA at each interview, was approved by the IRB of Research and Development Solutions, which is registered with the US NIH Office of Human Research Protection (IRB00010843).

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Disclaimer: There are no conflicts of interest

Funding for the intervention was provided by the Government of Punjab, Pakistan, through it Punjab Population Innovation Fund (PPIF) to the Akhter Hameed Khan. Data management, research and analysis were conducted by Research and Development Solutions through a Gates Foundation grant (INV-051108).

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