Policy-making in Pakistan's population programme

HEALTH POLICY AND PLANNING; 11(1): 30-51 © Oxford University Press 1996

Policy-making in Pakistan's population programmeAYESHA KHANJournalist/researcher, Islamabad, Pakistan

Pakistan launched one of the first population control programmes in the 1950s, yet has lagged far behindother countries in effectively implementing or developing its understanding of population programmes.This paper explores the policy-making process which shaped the programme in Pakistan in terms ofthe political considerations of the various military and civilian regimes, the role of religion in politics,the influences of Western donors (particularly USAID), and the effect of international developmentideology. The resulting instability of the population programmes is analyzed in terms of: a) the rivalrybetween the separate population and health programmes within government; b) the politically chargedproblem of over-centralized federal control over population; c) the unresolved and uneasy working rela-tionship between government and non-government organizations. The paper concludes that the con-flicts in these areas are directly related to the larger policy context in which they have evolved, andwithout addressing the latter, the population programme will remain victim to deep-rooted structuralproblems.

Introduction

When Pakistan launched its national population pro-gramme in 1965 it was one of the first countries totake this ambitious step. Yet 30 years later, the pro-gramme is remarkable for its lack of impact on con-traceptive prevalence and fertility reduction, not forits achievements. Much has been written on itsweaknesses, however little investigation has beendone into the broader context which createdPakistan's population programme, that is, the politicalcircumstances under which it evolved and theprecarious game of risk repeatedly played out bydecision-makers at the policy level. This is the moreinteresting arena, for it provides clues as to howfailure was made inevitable at the outset of majorinitiatives.

The following discussion chronicles three key periodsin Pakistan's population programme, identifying howpolitical leaders and bureaucrats came to identifypopulation as a problem in the first place, and howforeign funders stepped in to supplement and shapegovernment efforts to find a solution. The originalpattern of policy formulation gave shape to a popula-tion programme which has changed little to this day.Population, perhaps only slightly more than the othersocial sectors, has been given priority by governmentsaccording to political whims or donor pressures.

The instability which characterizes the programmeplays itself out in three main areas: a) the rivalrybetweeen the separate population and health program-mes within government; b) the politically chargedproblem of over-centralized federal control overpopulation; c) the unresolved and uneasy workingrelationship between government and non-government organizations.

Programme emphasis has remained on the supply sidesince 1965, despite a growing sophistication at theNGO and international level in understandingfamily planning, reproductive health, and wider socialdevelopment interlinkages. Government bureaucracyremains over-centralized and inefficient, thus ren-dering it unfit to solve the 'problems of the popula-tion'. Instead the programme remains focussed onthe 'population problem' and demographic targets,relying on dynamic individuals to help it meet itsunrealistic goals.

Putting population on the agendaVarious schools of Islamic thought have taken posi-tions on family planning and abortion, and Muslimsin South Asia usually adhere to these religious inter-pretations according to whatever tradition theyfollow. But the modern nation-state of Pakistan only

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Population policy in Pakistan 31

officially condoned family planning upon the urgingsof well-placed society women.

Elite women in South Asia have played a powerfulrole in demanding female education, freedom fromrestrictions of purdah, and legal rights. This traditionof activism was continued after the creation ofPakistan with the founding of the All-PakistanWomen's Association, the first women's organizationin the country. Begum Saeeda Waheed, active inAPWA and the wife of a prominent businessman inLahore, became an advocate of birth control whenher maid died attempting to abort a fourth pregnancy.The original logic for beginning the work was simplythe shock of discovering that a woman should haveto risk taking her life to control her own fertility.1

Waheed consequently founded the Family PlanningAssociation of Pakistan in Lahore in 1952.2 A closenetwork of family planning activists soon formed,linking Lahore with Dhaka in East Pakistan and witha group of activists and young demographers inKarachi.

The government's reaction to FPAP was mixed.Waheed was promised a token amount approved bya special Parliamentary vote in 1958, to be channelledto FPAP through the Ministry of Health. FPAPrealized that the allocation may just have been madeto be rid of the nuisance created by the vocal groupof well-placed Begums, or upper-class ladies, whichthey were; but for them a point had been made.

The major breakthrough which brought family plan-ning into mainstream development policy took placewhen the agenda of FPAP coincided with the interestof Ayub Khan, President and military ruler ofPakistan from 1965 to 1969. His imagination wascaptured by the problem of overpopulation, and theeffect this would have on national development. Thisis a subtle but important difference from the FPAPconcern with the ill-health of women caused bypregnancy; yet the two approaches coincided suc-cessfully in that they both prescribed family planningservices as a solution. This difference, however, wasto affect the relationship between government andnon-government population organizations in futureyears, as their paths diverged more often than not,and initial compatability of views gave way to opendiscord.

The glamour years (1965-1969)I. Ayub cultivated his demographic fascination indiscussions with economists from the Planning Com-

mission and meetings with the fast-growing FPAP.When FPAP held its first-ever national seminar inFebruary 1959, Ayub attended and spoke forcefullyabout the 'menace of over-population' which wasdestined to lead to a standard of living 'little betterthan that of animals' (Pakistan Times, February 25,1959). A National Board of Family Planning wasestablished at the federal level, with two subsidiaryorganizations for East and West Pakistan respect-ively. The Board advised the government on policy,while the ministry of health implemented the newcampaign. Personnel were trained and cheap con-traceptives distributed through government hospitalsand voluntary organizations such as FPAP. SaeedaWaheed and Alamgir Kabir, then Vice-President ofFPAP, joined the Board along with senior healthministry and planning commission officials.

The reasons for Ayub Khan's position are varied, buta few stand out because of the effect they had on theprogramme as it evolved into the 1990s. First, therole of religion in his government was not signifi-cant. Ayub Khan was a Sandhurst-educated militarydictator with little personal concern for the religiousposition on family planning. Unlike General Zia whowas to be the country's next long-term military dic-tator (1977-1988), Ayub did not seek a religiousmandate for his rule. In his address to the FPAPseminar in Lahore mentioned above, he made a com-ment that Zia would have considered blasphemous.'I cannot believe that any religion can object topopulation control,' he said, 'because no goodreligion can object to anything aimed at the better-ment of human lot, because all religions, after all,come for the good of the human race and humanbeings do not come into the world for the religions'(Pakistan Times, February 25, 1959).

When Ayub Khan was overthrown in a popularmovement in 1969, religious parties who joined inthe protest used the population programme todiscredit him morally. In demonstrations theychanted, 'Family planning, for those who want freesex!' and burned the programme's publicity hoar-dings. In 1971 the elected government of ZulfiqarAli Bhutto was thus careful to avoid the samereligious rancour, and General Zia, who relied onthe support of religious parties, froze the programmewhen he first seized power.

The second reason for Ayub's position was the in-fluence of the development ideology of his time.Economic growth, modern industrialization, higher

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per capita incomes - these were the catchwords ofprogress in the 1960s and the source of Ayub'spolitical legitimacy. He was a 'military modemizer',encouraged to wield his undemocratic powers toeffect strong, possibly unpopular programmes in thename of economic growth alone (Finkle 1972:109-10). Government economists and academicsfrom Harvard University, who assisted the PlanningCommission in designing both the First (1955-60)and Second (1960-65) Five Year Plans, urged thegovernment to recognize that even a 1.4% rate ofpopulation growth was a threat to economic progress.Ayub Khan took serious note of these early warningsbut found himself frustrated in his search for a quicksolution.3

Pressure was building on Ayub Khan to show thathis programme of intensive industrialization wasreaping tangible benefits in improving the standardof living of Pakistanis. The West expected Ayub tofulfill his promises of economic development, andpraised him lavishly when he was seen to succeed.'The survival and development of Pakistan is one ofthe most remarkable examples of state and nationbuilding in the post-war world', wrote The Times ofLondon in 1966 (as cited in Hasan 1986:88).

The third reason for Ayub's position on family plan-ning was its political utility. He was a military dic-tator of a poor country, in search of a developmentstrategy, and without any popular mandate to hisleadership. Like all other rulers of Pakistan, he reliedon support among the landed elite and moniedbusiness houses to stay in power, despite promisesin public that sweeping land and social reforms wouldtake place. Wajihuddin Ahmed, later Commissionerfor Family Planning, suggests that when Ayub wentto the US in 1959 and requested the oral pill for hispopulation control activities, he was actually usingthe Malthusian scapegoate as a substitute for anysubstantial socioeconomic reform programme. Bythe mid-1960s, when Ayub was pushing ahead forrapid industrialization and economic growth, hehoped that the 'eye-wash' of land reform and popula-tion control would work as a solution for themaldistribution of wealth.4

Later governments had to contend with the demiseof the notion that simple industrialization, matchedwith controlled population growth, would lead toeconomic and social development. In view of thefailures of Ayub's policies, population control on itsown came to be seen as a superficial and risky solu-

tion to the intractable problems faced by subsequentgovernments. Both Bhutto and Zia were to advocateit only when other religious, political, and financialfactors coincided favourably. In contrast with Ayub,they did not rely on the ideology of modem economicprogress to establish credibility with the people. Bhut-to was a popular leader, adored by the majority forhis charisma and socialist rhetoric, who came topower democratically. Zia deliberately contrasted hisrhetoric to secure the support of Bhutto's opponents.He chose the ideology of Islam to give his govern-ment legitimacy, and thus the religiously sensitivenotion of family planning was slow to find a placein his plans for the country.

The fourth important reason for Ayub's enthusiasmcame from abroad. Donor support was critical totransforming his ideas into a national population pro-gramme, and it has continued to play a pivotal rolein sustaining it ever since. As early as 1959 he visitedthe United States, fully aware that the West regardedhim as a mild, modern, even progressive dictator(Myrdal 1968: 327). President Eisenhower, whoseopposition to state interference in family planning wasknown, refused Ayub's request for the oral pill,which at any rate was not yet available for widespreaduse. Not to be deterred, he went to the PopulationCouncil in New York and requested an advisory mis-sion to help his government design a family planningprogramme (Notestein 1968: 555).

Thus non-government research and technicalassistance comprised the first donor input into thegovernment programme. The first population seminarorganized by the MOH and the Pakistan Institute ofDevelopment Economics in November 1959 wasattended by Dr MC Balfour, who also assistedthe government in preparing its first strategy.3

Malthusian doomsday theories were debated at theseminar alongside the ideas of Ansley Coale and EGHoover's famous 1958 book, Population Growth andEconomic Development in Low-Income Countries. Itargued that population control would allow familiesto accumulate more money for investment andthereby solve the problem of insufficient capital inpoor countries.

USAID was poised to enter the Pakistan programmeonly when Lyndon Johnson came to power and theUS Agency for International Development convincedhim that rapid population growth would underminethe effectiveness of all other development aid in poorcountries. Meanwhile Ayub was ready to launch a

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Population policy in Pakistan

Table 1. Family Planning Scheme for Pakistan during Third Five-Year Plan, 1965-1970

33

Targets Objectives Implementation

Prevent 5-6 millionbirths in next 5 years.

Reduce annual birthrate from 50 to 40per 1000 by 1970.

Cover all 20 millionfertile couples withservices by 1970.

Maintain present andplanned level ofincrease in per capitaincome.

Obtain self-sufficiencyin food, avoid imbalancein age structure ofpopulation.

Massive media publicity, aspart of public-relationsorientation of Scheme, insteadof mainly clinical bias.

Motivation at individual andvillage level through contact.

Motivation by bringing suppliesand services to doorsteps of thepeople.

Use of monetary incentives.

Employment of 50 000 villagedais; doctors, and healthvisitors.

Promotion of foam, condomsand sterilization. IUDs as majorprogramme method.

Administrative organization:Central Family Planning Council, along with Provincial and District Family Planning Boards, andUnion/Thana Councils to carry out implementation. The principal executive is the Family PlanningCommissioner, also Secretary in the Ministry of Health. The Council functions as a semi-autonomousgovernment body under the Ministry of Health, Labour and Social Welfare.

Major donors during this period:USAID, Ford Foundation, Population Council (funded by Ford and USAID), University of California(Berkeley), Johns Hopkins University (funded by Ford), Swedish International Development Agency,International Planned Parenthood Federation.

full-scale, nation-wide campaign, although he hadfailed to receive support from the US for distributingthe oral pill. Valuable lessons had been learned fromthe Second Plan activities implemented through theMOH, which indicated that the health infrastructurewas too immature to take on family planning (UnitedNations 1969: 126).

n. Pakistan's first comprehensive Family PlanningScheme (Table 1) was included in the Third Five YearPlan (1965-70). In 1964 the Population Council sug-gested to Ayub's high-level officials that it was timeto launch an independent family planning programme.On the basis of these recommendations Ayub tookthe decision not to rely on clinical services throughthe health infrastructure alone.6 The Scheme's ra-tionale, however, remained government's vision ofeconomic progress through increasing per capita

incomes. Of particular concern was the lack of ade-quate food-grains, expected to deepen with populationgrowth.

Details of this historic programme are of interesttoday since future family planning strategies becamevariations on the original Scheme (Robinson 1966,1978, 1987; Shah 1979; Rukanuddinetal. 1992; UN1969). Its most outstanding feature was its strongpolitical backing, due to reasons argued above, whichbrought a level of credibility and publicity to familyplanning which has never been achieved againsince. As a consequence of the money and hype, theScheme's only tangible success was to raise aware-ness and knowledge throughout Pakistan about con-traceptive availability (United Nations 1969). On theground, it suffered phenomenal problems of im-plementation. Some of the major flaws were: cen-

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34 Ayesha Khan

tralized administration with an over-dependency onkey individuals, alienation with the health ministryand consequently other departments, over-ambitioustargets and an extreme supply-side bias.

The man in charge of making it worth the Rs.284million allocation was Enver Adil, a dynamic civilservant who adopted what FPAP was later to criticizeas 'the steam-roller approach'. Enver Adil was anambitious man whose government career could soarif he won Ayub's praise. Under pressure, he boastedof too much success. 'During the year 1967-1968,'he wrote, '. . . [Our] Concept of standard of livingand per capita income became meaningful as well assignificant and the small family realised as a concretemeans and manifestation of that objective' (Adil 1969:10). The 1969 UN/WHO report, along with USAIDand World Bank evaluations, also praised theprogramme's successes (Pakistan Family PlanningCouncil 1969: 4-11).

It was a crash programme, designed to have a wideimpact in the shortest time possible. This wouldjustify the choice of Adil and his steam-rollerapproach, the autonomous and costly programme,and the political backing of Ayub. Full-time staff in-cluded 1392 Family Planning Officers, 1200 LadyFamily Planning Visitors, and 1209 Family Plann-ing Assistants. Among the part-time staff were 25 000traditional birth attendants, who earned referral feesfor clients they brought in (Ministry of Health 1965).

The tale of target-setting reveals the enormouspressure which Adil was under to prove that his pro-gramme was doing well. The Scheme set out toreduce the birth rate from 50 to 40 per 1000 by 1970,although the Planning Commission had provided amistakenly exaggerated figure of 50 to Adil. Over-ambitious targets forced programme staff to findcreative ways of providing measures of success tothe Planning Commission; measures of 'numbers ofbirths averted' and 'couple-years of protection', reliedon by the government until today, are a direct resultof an instrinsically supply-driven programme (Beanand Seltzer 1968).

There was an obvious discrepancy between officialclaims and the first research findings. The NationalImpact Survey (1968-69), conducted by the federalCouncil's Training, Research and Evaluation Centre(TREC) and assisted by Johns Hopkins University,revealed that three years after the Scheme began, only6% of married women were using any contraceptive

method (Shah 1979: 164). It also showed that thelevel of IUD use and retention was much lower thanthe government had estimated. It suggested a widerrange of contraceptives to be offered to the public,and a greater emphasis on outreach and motivationin order to reduce the gap between knowledge andpractice (TREC, nd: 70-71).8

The Scheme brought with it an autonomous admin-istrative and financial organization, with implemen-tation at die Union Council level linked with the civiladministration. A separate Division was created underthe MOH. This policy-level office was headed by thesame person in charge of programme implementation,the Family Planning Commissioner - Enver Adil.Provincial Family Planning Boards, headed by theirhealth ministers, were responsible for implementationthat was further sub-allocated to the local levels. Yetpolicy-making and basic responsibility for achievingthe targets rested with die federal government,mereby restricting ownership of die programme toa small sphere alone. The great show of donor sup-port, with population programme staff offered sal-aries higher than other government employees,created resentment within government against dieprogramme.

Although at the outset condoms were the mostavailable contraceptive method, by 1966 die IUDbecame the corner-stone of the Scheme. It wasconsidered the ideal contraceptive: safe, cheap,reversible, and requiring little user action. Even inter-national planners expected the IUD alone to reversefertility trends (Finkle 1986: 102). Population coun-cil experiments conducted in Karachi's new NationalResearch Institute of Family Planning were showingdiat it had a high retention rate and few side effects.Incentives were paid for every IUD inserted, as a con-sequence over-reporting and allegations of financialmisuse ensued. Poor follow-up helped to spread fearand misinformation about contraceptive side-effects.

The experimental nature of die Scheme did allow itto respond to some problems as tiiey were discovered.For example, the focus on IUDs necessitated a changein the programme, and traditional birth attendantswere almost fully replaced by a new cadre of para-medical Lady Family Planning Visitors to serve asIUD inserters. In May 1968 Ayub Khan issued adirective to enlist the services of medical facilitiesand doctors for contraceptive distribution, whichcould never be fully implemented because his govern-ment fell soon after.

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In search of a strategy (1970-1977)I. Ayub Khan was overthrown in 1969 throughagitation organized jointly by the left-wing PakistanPeople's Party and the right-wing religious parties.He was replaced by another army general, YahyaKhan, whose regime did little more than oversee thecivil war which divided East and West in 1971.

Wajihuddin Ahmed replaced Adil as Family PlanningCommissioner during Yahya's rule, and retainedhis extraordinary amount of individual policy-makingand programme-implementing power. He designedan experiment which, if successful, was supposed toimprove implementation and re-orient the programmefrom a supply to client-based approach. Wajihuddinwanted to focus on keeping women non-pregnant,rather than meeting contraceptive targets alone. Healso arranged for the oral pill to become availablefor use in Pakistan, another necessary departure fromAdil's IUD-based Scheme because the poor follow-up and over-promotion of this method had made itcontroversial. Despite his different approach, heshared with his predecessor a view that family plan-

ning could be delivered to the people through aneffective administrative machinery.9

These ideas were tested in a pilot project known asthe Sialkot Experiment. It began in 1969 and servedas the basis for the Continuous Motivation Scheme(Table 2) launched nation-wide in 1973, when theinitial healing of war wounds allowed for a renewedfocus on family planning. During this period, theinternational debate was raging over whether demo-graphy could or could not be changed through familyplanning activities. Wajihuddin claims the Sialkot Ex-periment was designed to prove one side false.Technical and material assistance for the Sialkot Ex-periment was readily available from Johns Hopkins,Berkeley, the Population Council, and US AID.

Initial results of increased contraceptive preval-ence at Sialkot delighted foreign and local expertsalike. The final push to turn Sialkot into nationalpolicy was easy enough. Since Wajihuddin was bothCommissioner in charge of implementation, and JointSecretary in the Ministry of Health and Family Plan-ning, the decision to expand his concept of field

Table 2. Continuous Motivation System and Contraceptive Inundation Scheme (1970-1977)


Reduce birth rate from45/1000 to 40/1000(in original FourthPlan, 1970-1975)

34% of married womenwill practice effectivecontraception by 1975

9.6 million birthsprevented

Maintain a growth ratein GNP higher thanpopulation growth

Rapidly reduce fertility

Double expenditure from ThirdPlan

Replace use of dais with male/female motivator teams

Emphasize sterilization and oralpills rather than only IUDs

Withdraw incentives andreferral fee system

Integrate health and familyplanning services at unioncouncil level

Expand CMS and addinundation scheme

Administrative organization:Structure of 1965 Scheme retained with changes at the local level. For example, country was dividedinto operational units of 8-12 000 population, with male/female motivator teams assigned to eacharea. They were supervised by one family planning officer for every 6 teams.

Major donors: US AID, UNFPA.

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motivation from Sialkot into other districts nation-wide was largely his alone to make. Young demo-graphers working on the Sialkot Experiment sug-gested the expansion was premature, but they wereignored in the haste to find another crash programmeas dramatic as the 1965 Scheme.

The civil war intervened to delay the nation-widelaunch. The country split apart and internationalassistance was suspended because of army atrocitiesin Bangladesh. When Zulfiqar Ali Bhutto's People'sParty took over government in 1971, the new govern-ment was left with little more than unserviceableinternational debts. Bhutto's first priority, like everyleader in Pakistan, was to stay in power. Since theanti-Ayub agitation had negatively politicized familyplanning, Bhutto avoided giving the religious right-wing an opportunity to use the same slogans againsthim. Further, the new government based its popu-larity on being anti-Ayub and representing theopposite of the pro-American and capitalist stanceassociated with the former dictator.

Unlike Ayub, Bhutto lacked an outright political orideological interest in population control, but this didnot tally with the thinking of US AID at the time.Joseph Wheeler, Chief of Mission of USAID inPakistan between 1969 and 1977, recalls, 'It was clearby 1969 that the issues of the coming decade werepopulation growth and East Pakistan rice. Clear tome, that is. From Pakistan's point of view the issueswere different. . . . USAID felt population was animportant issue and offered help.'10 MubashirHasan, Bhutto's first Minister for Finance andEconomic Affairs, recalls that the first overture wastoo soon after the war, and government prioritieswere rebuilding the army and finding funds withoutrecreating Ayub's dependency on western aid."

This was not to last long, as Bhutto soon discoveredthat the government could hardly fulfil its socialistpromises through financing services it could notafford. He took up the offer of assistance in popula-tion by calling a committee to review the programmeas a whole. The Aslam Committee (1972-73),chaired by the Health Minister, re-approved the CMSas the national programme for family planning. TheCommittee's impact was strengthened as the resultsof the 1972 Census were made public; they revealedthat Pakistan's poulation had grown from 43 millionin 1961 to 65 million, and fertility levels remainedunchanged (USAID 1975: 2). The Aslam Commit-tee also recommended basic infrastructural changes

which were never implemented, such as the completefederalization of the programme under the Ministryof Health, and the liberalization of abortion laws,raising of the marriage age for women from 16 to18 years, and close association with social welfareorganizations (Committee 1975: 23-24).

n . When USAID resumed full-fledged economicassistance to Pakistan in 1973, its own ForeignAssistance Act required it to support 'growth withequity', and thus the new focus became agricultureand the social sectors. Between 1964 and 1979, theyear USAID suspended aid to Pakistan for politicalreasons, it had spent over $30 million on Pakistan'spopulation programme; during 1965-75 US AID pro-vided 40% of total programme inputs (CDIE draft,1993: 8).

'America cared [about population] because there wascommitment from the highest level down that rapidpopulation growth was a hindrance to developmentin the Third World,' explains Steven Sinding, whoserved in Pakistan's USAID population project from1974 to 1978 and later rose to head USAID's Officeof Population in Washington DC. He adds that thisview has usually been strengthened with Demoraticleadership in the White House and weakened duringRepublican regimes such as Reagan's, which soughtto appease religious and right-wing lobbies at homeby de-funding USAID's population activities."

USAID's 1973 population project was rooted in thispolicy context, yet its stated goals in Pakistan weresomewhat mixed. Its original purpose was a broaderinstitutionally-oriented focus, whereas the USAID/Islamabad mission prioritized the delivery of con-traceptive methods (CDIE draft, 1993: Annex; 3).$20.6 million were provided for contraceptive sup-plies, in support of a major new addition to CMS -the Contraceptive Inundation Scheme (Table 2).Wheeler claims Inundation was intended to ensurea choice of family planning methods, 'which couldonly be achieved if public/private supply lines werefull and maintained.'12

Inundation was the brainchild of Reimert TRavenholt, a senior population officer at USAID inWashington, who believed that a large and readysupply of contraceptives would generate more de-mand for family planning and thus increase con-traceptive prevalence rates (Ravenholt 1968: 573).The translation of this thought into practice was, inPakistan, 'perhaps the ultimate effort to put into place

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a supply-oriented program' (Robinson et al. 1981:87). The plan was for condoms and oral pills to bedistributed through a network of 50 000 shopkeepers,health outlets, and fieldworkers, to make contracep-tives easily available throughout Pakistan.

The approach was extreme and unrealistic in its goals,but it grew out of a very real debate among popula-tion researchers at the international level. Thisbecame apparent during the 1974 Bucharest Con-ference on Population, when two views on fertilityreduction diverged. The public health services ap-proach, to which Ravenholt adhered, was primarilysupply-driven and considered fertility a function ofcontraceptives and availability. Conversely, the socialscience approach viewed fertility reduction as a func-tion of a nation's complete development.

Wheeler wanted Pakistan to work simultaneously onstrengthening both the system and the supplies infamily planning.10 Yet the debate continued withinUSAID and carried over into its Pakistan Mission.In 1974 Sinding criticized the Ravenholt approach atan internal meeting in Washington. He believes thatRavenholt gave USAID and the US government a badname by refusing to acknowledge that population hadother dimensions. Although Wheeler had beguntesting Ravenholt's ideas through the CMS and In-undation, he invited Sinding to set up a research pro-gramme in Pakistan to test out these new ideas.

• I . CMS and Contraceptive Inundation were neverimplemented as planned; they 'failed', in a sense,before they were put to the test. This could have beenavoided if internal warning signals were not ignoredin the rush to put in place a nation-wide programmethat would prove to donors and the government thatfertility rates could be reduced through family plan-ning services.

For example, Wajihuddin Ahmed proposed thegradual introduction of CMS over five years, but thewar intervened and later the Aslam Committeeapproved the all-out expansion in 1973. Dr AttiyaInayatullah, then a senior member of FPAP, alsorecalls telling the government that CMS requiredvariations for different parts of the country.13 Herview reflects the micro-perspective on local popula-tions which comes from NGO work at that level. Incontrast is a government view, still in effect today,that successful NGO or pilot projects can be repli-cated without subtlety across Pakistan's extremelyheterogenous population. Linked with this is another

government view, held from Adil's era until today,that family planning is an administrative matter. Thebureaucracy's failure to carry out the inter-personalmotivation envisaged in the CMS is thus no surprise.

Meanwhile, Contraceptive Inundation suffered froma logistical problem. USAID procured the supplies,but the system of distribution to outlets, many ofwhich existed only on paper, never took off. Aftertwo years of Inundation, the programme was able toreach only 15% of the market in the commercialsector. With the central warehouse in Karachi over-flowing, the reported condom user figures were ex-aggerated (CDIE draft, 1993: 10). In terms ofincreasing knowledge and access to contraceptivesamong the population, and reducing the growth ratefrom 3%, the 1975 Pakistan Fertility Survey revealedthat little had changed over the last 7 years (Robinsonet al. 1981: 88).14

The problem of over-centralization was not solvedeither. From 1976-77, the programme became fullyfederalized. The Population Planning Council inIslamabad became a division under the healthministry, with provincial organizations made depart-ments under Health at that level. The federal govern-ment was charged with policy formation andfinancing of the programme, while the provincialdepartments were to implement it. Financing, asalways, was to come from the centre. Finally, higher-ranking employees in population were made fullgovernment servants in an effort to improve theirstatus within the civil service.

The relations between population and health becameeven more strained during the Bhutto period. Theabove-mentioned moves to 'bi-furcate' the pro-gramme when population became a division with aseparate Secretary under the MOH further alienatedpopulation from health services. The result was thatthe individual power of the new Secretary within thecivil services was undisputed, true to the tradition ofthe programme leadership thus far, and this amidstgrowing hostility to population from surroundinggovernment departments.

By this time USAED had developed its own misgiv-ings. From 1973 to 1981 cumulative commitmentsof USAID in all sectors totalled $5.1 billion. Out ofits 1973-77 Population Planning project, the Inun-dation Scheme was its largest single budget item,although 'no comprehensive analysis such as market-ing and economic studies was made to determine the

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effect of inundating Pakistan before [US]AID com-mitted funds' (CDIE draft, 1993: 5-8). This suggeststhat although the donor role in Pakistan's programmehad grown enormously during the Bhutto era, it wasnot very effective or responsible. USAID, with manydollars to spend, rushed its Inundation Schemealthough it was obviously supply-focussed and in con-tradiction to the CMS client-based approach.

There was deep donor disillusionment with Pakistan'smanagement as well, with the 1976 USAID evalua-tion concluding that CMS had not increased deliveryof contraceptives effectively, the government had notmanaged the huge population investment in line withany comprehensive national strategy, and that despitegrowing expenditures there had been no decrease infertility over the last 10 years (CDIE draft, 1993: 8).Wheeler states, 'In retrospect I think one could saythat USAID made a high risk bet that governmentmanagement and political support would matchgenerous US assistance. We lost that bet. But theissue is of such importance that in my view, it wasright to try.'10

By 1977 USAID was prepared to resolve some of themanifold problems within its own Pakistan projectby finding innovative ways to create demand for ser-vices, and studying how alternative determinants offertility could be addressed through the public sec-tor in order to reduce growth (CDIE draft, 1993: 10,Annex: 11). If it had succeeded, it might have stimu-lated debate in Pakistan over how causes of high fer-tility, rather than merely the phenomenon of frequentchild-bearing, could have been addressed by the na-tional population programme.

However, by this time the Bhutto government wastottering. The opposition movement included in-dustrialists and middle-class traders disillusioned withBhutto's policies, and given a strong voice byreligious leaders. Population became more sensitiveand even less of a priority than ever. Bhutto first triedto appease the new pressure groups by declaringFriday, instead of Sunday as a national holiday, andbanning alcohol. This pattern of granting symbolicconcessions to the religious right-wing began underBhutto and was taken to its greatest extreme byGeneral Zia ul-Haq, the Chief of Army Staff, whodeposed Bhutto and declared martial law in 1977.

The programme persists (1977-1994)I. The present key period in Pakistan's populationprogramme is the longest and most complex thus far.

With the government of General Zia ul-Haq, factorsinfluencing policy-making which were already woveninto the Ayub and Bhutto periods now became exag-gerated and explicit. Whereas Bhutto and Ayub suf-fered the interference of the religious right-wing withtheir ideologies of politics and development, Ziamade the religious right-wing his political ideology.He used the conservative middle-classes and religiouslobbies to win initial support for his military take-over. His rule was designed to negate the ideologyof Bhutto's People's Party, and over time break thepopular support base which Bhutto enjoyed despitehis fall from power.

Zia froze the population programme when he firstassumed power in 1977. One stated reason for hisdecision stemmed from the widespread belief thatBhutto had used PPP workers as field motivators. Allpolitical activity, including anything that couldpossibly have mobilized the public in favour of Bhut-to, had to be suppressed by Zia during the early, andmost fragile, period of his rule. His subsequent banon publicity for family planning activities was oneof many gestures to his religious constituency, tradi-tionally opposed to birth control programmes, thathe was serious about Islamization.

Women became the symbol of his ideology. In 1979he promulgated a series of Hudood Ordinancesprescribing punishments for theft, rape, intoxication,and adultery, according to Saudi Arabian interpreta-tion of Islamic law (Wahhabi'ism). Sex outside mar-riage became a crime against the state, punishableby death. Until today, fornication and rape are nottreated separately, and the onus of proof of innocenceon the first charge lies with the woman, and as forthe second, if she cannot prove she was raped shebecomes liable for charges of adultery. Jails becamefilled with women accused by their menfolk ofadultery. Although the maximum punishment wasnever carried out, it caused an increase in violence,especially state-sponsored attacks, against women anda deep sense of insecurity took root among them(Jehangir and Jilani 1990).

The international-level debates on population issues,which had earlier prompted experiments in Pakistan,were now subsumed in importance to the crudepolitical agendas not only of government but thedonors as well. USAID's assistance was suspendedtwice during these years of political crisis and harshmilitary dictatorship. First, from April 1976 toSeptember 1978, assistance was frozen as a result of

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Pakistan's nuclear programme. Second, from April1979 to 1981, assistance was banned following theburning of the US Embassy in Islamabad and politicaldifferences between the US government andPakistan's military regime.

Zia's process of Islamization and human rights abusesinitially alienated him from the Western powers thatAyub Khan had so carefully cultivated. If die inva-sion of Afghanistan by Soviet forces in December1979 had not suddenly made Pakistan a strategicallyimportant country for die United States, it is unlikelythat his regime would ever have received internationalpolitical and financial support. As it turned out,money flowed in during the 1980s for population aspart of Pakistan's obvious reward for playing the ColdWar game to the tune of the West.

With population policy more grossly subject • topolitical manipulation and donor support than ever,problems with the programme only deepened, par-ticularly in regard to its over-centralization, its rela-tionship with health, and the role of non-governmentorganizations. When Zia allowed the programme torestart in 1980, efforts began to resolve these issuesdespite obvious impediments. These remain evenafter the resumption of elected government in 1988.

In 1980 Zia put Dr Attiya Inayatullah of FPAP incharge as Advisor on Population. She had a wealdiof experience in delivering services effectively onthe non-government level, and understood the linkbetween fertility reduction and improvement inwomen's status. However, her effectiveness as Zia'sadvisor was clearly undermined by the increasedvulnerability of Pakistani women caused by the verygovernment she now represented.

Yet the appointment of a high-profile, competent pro-fessional suggests Zia was making a firm commit-ment to finding long-term solutions to intractableproblems and involving NGOs in the process.Inayatullah claims mat Zia gave her a 'blank cheque'to do as she wished. Dr Mahbub ul-Haq, Ministerfor Planning and Development and Minister in chargeof the Population Division from 1982-86, says theonly instructions he received from Zia were to quiedygo ahead with the programme without involving thePresident.13 Zia himself did not advocate familyplanning publicly, nor did he allow effective mediacampaigning. Therefore the government was actuallyminimizing its risks. Zia reinforced the tradition ofappointing high-profile individuals to put an effec-

tive face on a programme which the government didnot know how to institutionalize or stabilize.

Speculation persists about his motives for re-launching die programme at all. For example, JohnBlackton, with US AID in Islamabad during the1980s, argues that Zia was under external pressurefrom the United Nations, USAID and the World Bankto show that something was being done in primaryeducation, health and population. He says the appoint-ment of Dr Inayatullah 'was a frequent device of theGovernment to put someone in place to make it seemlike somediing was happening'.16 The availability offunding possibly increased Zia's tolerance, as sug-gested by Dr Haq's comment: 'I could sense I couldget any amount of money any time from [donors]for population'. The appointment of Dr Nafis Sadikas Executive Director of the UNFPA in 1987, whichhad to be approved by her own government, helpedto boost die government's image at home and abroadthat it was serious about population.

When USAID moved back into Pakistan in the wakeof changed political realities, it was eager to makefriends with General Zia's military regime. In 1981a $3.2 billion aid package, half of it for militaryassistance, was negotiated for the period 1982-87(CDIE draft, 1993: 6). The Project Paper forUSAID's $25.6 million grant for Population Welfarestated: 'The military-security-political position ofPakistan, including the burden of a massive [Afghan]refugee influx, accentuates die development problemto which the proposed US economic assistancepackage responds' (USAID 1982: 7).

USAID was not involved during the reconceptu-alization of Pakistan's population strategy, which inpart explains why their own input during the 1980sdid not reflect any major innovation or rediinking ontiieir part. The $25.6 million was enhanced by anotiier$14.4 million in 1986 to purchase additional con-traceptives for the project. $45 million were furtherallocated during the project period, to support theSocial Marketing of Contraceptives, a more sophis-ticated version of Inundation. Contraceptive suppliesremained USAID's largest input into the programme,despite USAID's policy to add training and EEC com-ponents during the 1980s. At the close of activities,an internal evaluation concluded that '[US]AID didnot contribute to financial sustainability in the popula-tion sector' (CDIE draft, 1993: viii).

In retrospect, the political contingencies and contextof US assistance to Pakistan made this harsh verdict

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40 Ayesha Khan

inevitable. Despite obvious failures in population dur-ing the 1970s, US AID was politically bound to com-mit large funds to Pakistan, and its own mandatecompelled it to prioritize population as part ofdevelopment assistance. The Pakistan governmentknew US assistance would continue flowing in as longas the US government relied on General Zia to sup-port their policy on Afghanistan. Those who had mostcontrol over the highest-level financial and implemen-ting decisions relating to Pakistan's population pro-gramme did not believe they stood to lose much ifthe programme failed.

Zia's fear of religious opposition lessened as thedonor funding began to pour in for the renewedpopulation programme. A 1984 report issued by theCouncil of Islamic Ideology (CII), whose role is toensure that the government only enacts legislationwhich is in accordance with Islamic teaching, con-cluded that the population programme in Pakistanshould be abandoned. 'Because of birth control, thecountry shall suffer a turn to apostasy, shamelessness,and sexual corruption on a national level. And thecountry will suffer from a shortage of manpowerwhich is needed for national defence and economicdevelopment' (CII 1984: 81). This report was meantto be circulated in Parliament, to force a vote outlaw-ing the population programme because it violated theConstitution of Pakistan by being against the spiritof Islam. As with many of the CII's recommenda-tions, this one too was better left ignored by Zia'smen and never made it to Parliament.

By this time the political reality of Zia's decision toput Inayatullah in charge did not prevent her fromambitiously revamping the national population pro-gramme on an unprecedented scale (see Table 3). Inan unusual broadening of the policy-making process,the 1983-1987 Sixth Plan programme draft wasstudied by a 'Population Sector Working Group' ofleading international experts before it was finalized(Robinson 1987: 108). UNFPA, influential as theonly donor supporting the Population Welfare Pro-gramme during the early years of martial law,recommended that for the vital integration of Popula-tion with Health, other organizational changes neededto take place, such as provincialization of the pro-gramme, reorganization of the federal PopulationDivision (along World Bank suggested lines), com-mercial distribution of contraceptives, and completeregularization of all population staff as governmentservants (UNFPA 1979).17

n. Launching a'multi-sectoral strategy'in 1983 didnot transform the Population Programme radically atthe implementation level, but it did present a newrealization that issues of population were best ap-proached through integrating service delivery withother development initiatives. The years since thenhave been taken up with reworking, stream-lining,and experimenting further with the basic integratedand multi-sectoral premise. Outstanding programmeissues, unresolvable in a context of policy formula-tion still highly subject to political and donor exped-iency, continue to prevent ambitious plans frombecoming reality.

Merging family planning with healthThe Pakistan government seems aware that a mergerbetween population and health might resolve someof the manifold problems of bringing family plann-ing services to the people. Yet the politics of powerwithin the bureaucracy have so far hindered the pro-cess of making the idea a reality. In 1978 GeneralZia brought family planning activities directly underthe MOH and abolished the separate Secretariatwithin Health which was won during Bhutto's rule.A full merger between population and health was noeasy task, especially since a separate administrativesystem for population had been in place since 1965.Still, the health ministry requested the Planning Divi-sion to organize a meeting of experts and bureaucratsfrom all the provinces in order to work out themodalities of a phased integration of all componentsof health and population programmes. The plan wasnever implemented.

It is alleged that USAID argued against the mergerand provincialization on the grounds that the healthinfrastructure as well as the provinces were ill-prepared to take over full responsibility for popula-tion.18 It is unlikely that USAID was opposed tointegration per se, as the 1976 evaluation mission ofits population project in Pakistan did recommend anintegration with the health sector (CDIE 1993, draft:10). But, many of the 1976 evaluation recommend-ations were ignored when USAID designed its newpopulation project for Pakistan (1982-87).

When Zia shifted the Population Welfare Divisionto the planning ministry in 1981, population gainedonly part of the intended increase in status. In fact,the Secretary of the Ministry of Planning andDevelopment wanted to abolish the Family WelfareCentres and make health activities the major outletsfor family planning.19 He alleges that the Advisor

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Population policy in Pakistan

Table 3. Details of the multi-sectoral approach as laid out in the Sixth Plan (1983-1987)

41


Reduce birth rate from40.3 to 37.3/1000 by 1987

Increase contraceptiveprevalence rate from 9.5%to 18.6% by 1988

Reduce rate of growthfrom 2.87 to 2.69 by1987

If above achieved, then0.5 million births willbe prevented per year by1987-88 (Sixth Plan)

Create a holistic approach,integrate family planningwith development planning

Differential target groupapproach, making use ofother infrastructuralopportunities

Demand creation throughusing target groupinstitutions, mass mediaand socio-legal measuresto indirectly reducefertility

Emphasize NGOs and localauthorities' role, withimplementation responsibilitymainly with provinces

Broaden services of FamilyWelfare Centres to includehealth and skills training, andincrease their number from900 to 1250

Stronger institutional emphasison research

Utilize public and private clinicoutlets to widen availability,also include treatment ofinfertility

Commercial marketing ofcontraceptives to stimulatedemand and increase availability

Administrative organization:Population Welfare Division, headed by Secretary within the Ministry for Planning and Develop-ment, of which it is a part. Advisor to President on Population plays major policy-making role. Federallevel also has a National Council for Population Welfare Planning to formulate policy and reviewprogramme. It is chaired by the President and includes senior government functionaries.

Provincial Councils for Population Welfare Planning have key bureaucrats, private sector represen-tatives, and NGOs as membership, and are chaired by Chief Minister. District Councils are principalimplementors of programme, with District Population Welfare Officer as responsible officer.

Donors: USAID, UNFPA, World Bank, ODA (UK), CIDA.

Inayatullah resisted his idea because it meant theabolition of the population 'empire'. His accusationtouches a sensitive chord in all population staff to thisday; that is, as bureaucrats their power is increasedif they manage this heavily-funded domain separatelyfrom health, which in turn stands to gain much finan-cially and in terms of power enhacement from a fullmerger.

The issue began to near resolution with a 1985 deci-sion by the senior-most National Economic Council,ECNEC. It directed that health personnel be trainedin family planning techniques and that all Basic HealthUnits offer the full range of contraceptive devices(ECNEC 1985). This may have been one high-leveldecision in population policy which took placewithout donor influence."

But the orders never got to the ground, as evidencedby Prime Minister Nawaz Sharif s government whenthe new national health policy in 1990 repeated therequirement that all health outlets offer family plan-ning services (Rukanuddin and Hardee-Cleaveland1992). The World Bank went one step further andrecommended the full integration of Maternal andChild Health Services with family planning services- in recognition of the linkage between high fertilityand infant mortality rates (World Bank 1989:150-51).

This concept was to become part of wider social sec-tor strategy as the World Bank assisted the Pakistangovernment in developing a Social Action Pro-gramme in 1992, to integrate all social sector pro-jects to work towards the combined goals of reduced

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42 Ayesha Khan

population growth, basic education, rural develop-ment, water supply, and sanitation. An on-going pro-blem the Bank identified was the need to mobilizeworking level health staff to deliver family planningservices (Ministry of Population Welfare 1993: 1 andAnnex 5:11-12). UNFPA's current Country Direc-tor, Nesim Tumkaya says the donors and UN Systemhave been strongly advocating a full merger since the1990 decision to integrate field services.20

The new government of Prime Minister BenazirBhutto took an initiative soon after coming to powerin 1993 to train 33 000 village-based health workersthrough the health ministry (Table 4). These femalefield staff will provide basic preventive health, nutri-tion, and family planning services at the village level.At first it seemed that the Ministry for PopulationWelfare was destined to suffer a setback to its ownnew village-based family welfare workers' scheme,but that was not to be, as Bhutto's initiative will beimplemented through the health ministry. The suddenappearance of an ambitious 'scheme' which createsmany jobs and has not been systematically tested isreminiscent of Adil's Scheme and the CMS days,when the government was in a rush to find a projectthat would show quick results.

Integration is more likely than ever today because itis now a conditionality for SAP funding. That is, theMinistry of Health is required to deliver family plan-ning services, and donor funding will only follow im-plementation of this recommentation (Ministry ofPopulation Welfare 1993: Annex 1:4).

Devolving federal controlThe Pakistan government has traditionally operatedwithin a highly centralized framework. The isue ofdevolving federal control to the provinces is extre-mely politicized and the future of the nation will hingelargely on how this issue is resolved. The popula-tion sector has suffered because of this problem, moreso since 1976 when the Programme was fullyfederalized. In 1979 UNFPA suggested provincializa-tion as the first step in the transition towards the fullintegration of population with health, which wasalready the responsibility of the provinces (UNFPA1979: 64).

In 1983 Inayatullah set out to begin the process ofprovincializing the population programme, becauseoptions were running out. Population had originatedoutside government and then joined various federalministries without much success, so diat little choice

was left but to explore its luck with the provinces.Provincial councils were created for populationwelfare planning, with district councils as the mostimportant implementors of the activities (Robinsonet al. 1981: 109). Funding for all population activitiesin the government sector, however, remained part ofthe Federal budget's Annual Development Plan.

The government reduced the number of staff inpopulation, in an attempt to create a cadre for popula-tion workers equivalent to the formalized cadre ofPost and Telegraph within government. After a periodof initial rebellion, existing population staff were re-quired to take the same Public Services Commissionexam which other government servants must take tobe regularized. Those that refused were fired, andthus the staff was reduced from 16 000 to 8300.

After this episode, the relations between federal andprovincial population departments became more sen-sitized. Although the government promised decen-tralization, it was - and still is - unable to work outthe modalities. According to Inayatullah one reasonis that the Constitution of Pakistan declares popula-tion the responsibility of the federal government. In1983 a Presidential Ordinance was issued transferringfield activities to the provincial governments, whilepolicy-making and finance remained at the centre, asconstitutionally required.

Pressure to proceed with full decentralization, tobring not only budgetary allocation but also policy-making to the provincial level, has gained in momen-tum over the last 15 years. Today the provinces havelittle input in policy, they simply adopt the targetsset for the Five-Year Plans by the centre and do theirbest to achieve them. Over-centralization of funds isanother problem for provincial population staff, whorely on the federal government to release money foreven the most minor expenditure at the local level.

The Programme as run from the centre has not beensuccessful, giving donors reason to push for thismajor policy, and legislative, change. To begin, theturnover of Federal Secretaries within a period of 25years was almost one per year. With each Secretarywielding enormous individual decision-makingpower, this has often exacerbated the smooth work-ing of Population with related ministries such asHealth or Education. As UNFPA's Nesim Tumkayapoints out, obstacles to smooth cooperation stem fromindividual rather than institutional animosities.

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Table 4. Modifications of the multi-sectoral approach during Seventh and Eighth Five-Year Plans1987-1998)


Seventh Plan 1987-1993Lower crude birth ratefrom 42.3 to 38/1000

Increase contraceptiveprevalence rate (CPR)from 12.9% to 23.5%

Prevent 3.17 million births

Accelerated Programme 1991:

Increase in child survivalwill help reduce fertility

Overcome inadequaciesin service availabilityand involvement of othergovernment sectors

Reduce infant and childmortality

Involve all health outlets inservices

Include mobile service unitsfor areas not covered

Open 45 new contraceptivesurgery centres, train ladydoctors at sub-district level

Launch wider communicationseffort, have visible andsustained political commitment

Eighth Plan 1993-1998Raise CPR from 14% to29%

Reduce total fertilityfrom 5.9 to 5.4

Reduce crude birth ratefrom 39 to 35/1000

Prevent 4.66 million births

Reduce population growthrate from 2.9% to 2.6%

Total programme outreachto expand from 20% to 80%of population

Increase rural coveragefrom 5% to 70% and urbancoverage from 50% to 100%

Demand creation forservices throughcommunication

Use 12 000 village-based familyplanning workers to providecounselling, supplies andreferrals

Involve all health outlets andprivate medical practitioners inservice provision

Strengthen supervision,monitoring, feedback at locallevels

Emphasize clinical methods,i.e. IUD, injectable andcontraceptive surgery

Upgrade IEC and inter-personal motivationapproaches

Use of private sector throughSMC, hakeems, homeopaths,traditional birth attendants,medical professionals

Major donors: USAID, UNFPA, ODA (UK), Asian Development Bank, CIDA, WHO, SocialAction Programme funding, World Bank, European Community (expected)

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44 Ayesha Khan

Lack of communication within the federal sectors re-mains a problem, and equally weak are theprovincial-federal communication links.21 The on-going position of the Population Welfare Division,since promoted to a ministry in 1989, has been thatthe provinces lack the political will and infrastruc-ture to assume ownership of the Programme (Ministryof Health 1994). This is partially true, given thatpolitical commitment at the provincial, district, andlocal levels is weak for social sectors as a whole inPakistan, a problem separate from the high-levelpolitical leadership which is more often viewed asan indicator of commitment.22 Existing health ser-vices, administered as a provincial responsibility, arealmost as inadequate as family planning services, in-dicating that provincially-owned programmes haveno guarantee of success.

Nevertheless, decentralization has become a mainconditionality for World Bank support to Pakistan'sPopulation Programme. This sector is critical to thenew Social Action Programme, during which federaland provincial governments, as well as donors, willcoordinate their planning and funding to fit into acommon set of goals. The World Bank has playeda leading role in designing the SAP approach withthe Pakistan government, in an effort to ensurethat future social sector funding will be fully and ef-fectively utilized to improve human developmentindicators.

The World Bank acknowledges the need to phase theprocess of decentralization to the provinces withcareful planning. Its inside role in policy design isillustrated by its assistance to the Pakistan govern-ment to draw up a schedule of policy issues andactions to correspond with its wide-ranging recom-mendations. World Bank assistance to populationfrom 1995 will take the form of reimbursal forgovernment expenditure on a given project, a depar-ture from old-fashioned bi-lateral grants and tradi-tional loans which have been the mainstay ofpopulation funding and were allocated before theywere spent. The new tone of severity is unmistakable:'Evidence of sustained implementation progress ofthe program (and the associated reform matrices)under the SAP [Project] would be crucial inputswhen the final decision is made on whether to pro-ceed with the first year of the PWPP (in the jargon,they would be key up-front actions)' (Ministry ofPopulation Welfare 1993: 9).

There are two important reasons why completedecentralization will still be difficult. First, the

provinces feel the federal government should eitherincrease the share of its regular provincial allocationsto include population, or it should guarantee separatefunds for population for an indefinite time period.This is a difficult commitment for the federal govern-ment, since it regularly readjusts its own budget forpopulation on an annual basis to cope with exten-uating circumstances or changing priorities.

Second is the option of making population expen-ditures subject to the approval of the provinciallegislatures. Provincial parliaments would be free toadjust the Population Programme to suit their ownlocal needs and the federal government would endup with no effective control over population pro-grammes or policies. Since population is a concurrentsubject in the Constitution, this latter option wouldviolate its mandate. Recent intimations by the popula-tion ministry and UNFPA, however, suggest that thegovernment is planning to resolve the problem nextyear via the first option, by giving provinces addi-tional funds to be used for stipulated populationexpenditures only.7-20 Thus, full ownership of popu-lation by the provinces will not take place.

Agreeing on a role for the NGOsThe last 15 years have witnessed a slight move todecentralize control not only within governmentbureaucracy but outside it in the non-government(NGO) and private sectors as well. Considering thatthe country is fraught with problems of nationalidentity, demands for more provincial autonomy,economic fragility, political rivalries, and so on, thecentral government finds itself in the awkward posi-tion of recognizing its own insecurity and still beingpressured to give over control in the name of largernational interest.

Some of this power-struggle has been played out inthe population sector, where the main actors -government, donor, and NGO - have been unableto strike a workable relationship. In the 1950s FPAPhad the unmistakable lead in guiding the governmenton population issues, and during the 1965 SchemeFPAP and the government developed differences inapproach but continued to cooperate. In still morerecent years the NGO/government relationship hasdeveloped deep, perhaps unresolvable rifts.

The multi-sectoral approach as outlined in the SixthPlan envisioned the creation of the Non-GovernmentOrganizations Coordinating Council (NGOCC) to in-stitutionalize the role of NGOs in population. The

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government was to fund this new council and pro-vide it secretarial support at the Population WelfareDivision. The government took the largest risk withthis experiment. While FPAP and smaller NGOsstood to gain from more readily accessible funds andencouragement to set up family welfare projects, anddonors such as USAID could broaden their supportand outreach to NGOs through a coordinating coun-cil, government was unaccustomed to giving overcontrol. Thus, the Population Welfare Division ap-proached the NGOCC with its usual administrativeeye and set impossibly high targets for the numbersof family planning outlets it was to fund in the NGOsector for each Five-Year Plan. This restrictedNGOCC's flexibility and minimized the risk that itwould spin off on a different tangent of programmeor policy.

The first donor to provide funds was the CanadianInternational Development Agency (CIDA). It gavean initial $400 000 to make up for a shortfall bet-ween stated government allocations to the NGOCCand actual funds available for the year 1985-86. Thiswas the first sign that government was not fully sup-porting the new institution. The earliest evaluationsof NGOCC revealed that it was under-staffed, lack-ing the requisite skills to manage its finances and tomonitor and evaluate the NGO projects receivingfunds (Khan 1994). These serious institutionalweaknesses were acknowledged by CIDA, andalthough they remained, no party involved withNGOCC worked to strengthen it until 1990. CIDAcontinued to fund it with $500 000 per year for threemore years. By 1989 NGOCC had expanded its net-work to include 139 NGOs receiving its funds tooperate 550 service centres. USAID, UNFPA, andseveral international donors stepped in, but thedemand always exceeded available funding. Giventhe immense institutional weaknesses of NGOCC, itis no surprise that its achievements fell short of itstargets (Population Technical Assistance Project1991: 37).

Prime Minister Benazir Bhutto's government an-nounced in 1989 that NGOCC was corrupt and spen-ding funds illegally. At the same time it becamewidely believed among donors and NGOs that thenew government was using NGOCC to fundorganizations for political purposes. CIDA orderedan audit of NGOCC's accounts, and although nofinancial misappropriation was discovered, it did notcommit further money to the experiment.

The NGOCC mandate expired in 1993. The next con-troversy began over the form of its reconstitution.UNFPA, ODA (UK), and the European Community,which is offering $7 million to fill in the gap left byUSAID, all strongly push for NGOCC to be re-constituted with full autonomy from the government.It is a very strong joint NGO and donor position thatNGOCC be able to function without interference fromthe Ministry for Population Welfare and that it receivea steady source of funds.20 A compromise positionhas been reached with the ministry for NGOCC tobe reconstituted with a government endowment, inplace of annual budgetary disbursals, and minimalofficial involvement.

Yet freeing NGOCC from close government controlmay not resolve the underlying mistrust between thegovernment and NGO sector, especially since thegovernment has proposed new legislation to curb theindependence of NGOs. Attiya Inayatullah believesthat the government feels threatened by the NGOs'out of its own incompetence' and its inability toorganize the social sectors. Dr Siraj ul-Haq explains:'NGOs in the long run can change the social set-upand that is what the government is afraid of. If thethreat does run this deep, then even donor pressureto extricate the NGOCC from federal control will notturn the relationship between the two sectors into apartnership of development, as envisaged by NGOleaders and advocated by donors.

A thorough assessment of what has gone wrongwithin government, donors, and the NGO sectorwould have to critique the persistence of donors infunding projects despite poor results and evaluations.The donors' preference for the non-government sec-tor is linked with three issues. First is that govern-ment does indeed feel threatened by the NGO sector.Second is that this problem is being accommodated,not resolved, by donors' insistence that the reconsti-tuted NGOCC be fully autonomous; allocating ma-jor funds to it while it lacks the capacity to utilizethem effectively would demonstrate the same ir-responsibility of the first experiment. Thirdly, ifblame is to be apportioned for lack of support toNGOs in population, then donors must carry theburden along with the population welfarebureaucracy. They have funded the government pro-gramme heavily since its inception and thus haveclosely nurtured the fundamental 'administrative' andsupply-based approach towards population planningin Pakistan that is proving such a hindrance to its suc-cess today. The turn to NGOs for inspiration and in-

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46 Ayesha Khan

novation reveals how stagnant both government andits major funders in population have discoveredthemselves to be.

In search of solutionsThe above discussion has elucidated patterns evidentin Pakistan's population policy on two levels. Firstis the political context in which the policy of 'popula-tion control' has been rooted. This context has beeninfluenced to varying degrees during the Ayub,Bhutto, and Zia periods by the role of religion inpolitics, the influences of Western donors, the effectof international development ideology, and thepolitical utility of the population programme to eachgovernment. Second, over the last 35 years Pakistan'spopulation programme has been riddled with prob-lems of implementation that have essentially remainedunchanged. These include an over-centralized andbureaucratized programme which relies too much onthe power of 'key individuals', a poor working rela-tionship between the government and non-government sectors, and a lack of coordination bet-ween population and health within government. Thesedeep-rooted structural problems within the pro-gramme cannot be resolved without addressing thepolicy context in which they have evolved.

Through the 1994 United Nations Conference onPopulation and Development, the international arenahas sanctioned the need for cooperation betweenfamily planning and health services, and governmentand non-government organizations, in order to in-tegrate human development with reproductive healthconcerns. The Cairo Conference enthusiastically en-dorsed the modern notion of sustainable development,which views people, especially women, as subjectsand not objects of programmes. Today's populationprogrammes are thus compelled to reform themselvesin line with the priorities of women's health and well-being; this means reproductive and child health, andthe enabling legal, social and economic conditionswhich make family planning a real and safe optionacceptable to both the state and its citizens (see Senet al. 1994). The days of pushing contraceptive ser-vices as a means to reduce female fertility accordingto pre-set demographic targets are officially over;even Pakistan has signed the Programme of Actionwithout reservation.

Yet each country has specific policy constraints whichcannot be resolved, despite die best of stated inten-

tions, unless there is a favourable confluence of fac-tors. In Pakistan, international and domestic agendascoincided during Ayub's government to produce apopulation programme, but one which was a clearreflection of the top-down, non-participatory ap-proach characteristic of a military dictatorship. Asthe population programme faltered or gained groundin subsequent years, its working consistently reflectedthe functioning of governments obsessed with re-taining control at the centre, winning foreign funding,and appeasing religious opposition. In consequencethey limited the human development of women,restricted NGOs, and stifled public consensus onpolicy issues.

As die international development agenda changes, thepolicy context in Pakistan may be just responsiveenough to secure foreign funding, but deeper politicaltransformations need to take place domestically inorder to bring the ideals of Cairo down into theworkings of the population programme. The currentpolicy context, in which a series of unstable civiliangovernments have recently ruled, looks bleak forserious human development initiatives. Today'sgovernment lives on the edge of bankruptcy, bur-dened with international debt and the harsh humanconsequences of financing restructuring. It is strug-gling to survive until the next elections under thethreat of another dreaded martial law. Such a weakgovernment lacks the support of an informed politicalleadership and an engaged public, without which itcannot rethink die logic of its population programmeor address the highly politicized, chronic problemsof implementation.

ConclusionToday, Pakistan's population programme stands ata threshold, along with omer programmes in diesocial sectors; die time has come where government,donor, and non-government organizations know dieymust cooperate to achieve tangible results. The storyof policy formulation in population has uncoveredmajor stumbling blocks which have contributed to theprogramme's ineffectiveness. Recent efforts to in-tegrate social sector planning, led by me World Bank,may seek to address these key issues of inter-ministerial cooperation, provincial ownership of pro-gramme and policy, and partnership widi NGOs, butdiey cannot force harmony. There is a perceivedpolitical price, which Pakistan's leaders have beenreluctant to pay, for implementing a strong popula-tion programme; and in addition to diis is the much

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more serious problem of devolving power inorder to implement this, or any other programme,effectively.

On the part of all the major actors involved in thepolicy-making process, there is no evidence thatrepeated failures have led to a fresh look at the prob-lem itself. The World Bank and UNFPA, for exam-ple, continue to insist upon the severity of Pakistan'spopulation crisis, and the government repeatedlydeclares its commitment to reducing the growth rate.Agreement on this count has never seemed easier toachieve, while the problems of implementation ap-pear to be growing along with the number of peoplein Pakistan. NGOs are pre-occupied with the crisisof inadequate funding and the lack of support theyreceive from the bureaucracy, and by and large theytoo have adopted the mind-set of 'population control'.

In the absence of a wide-ranging population pro-gramme which addresses first and foremost the prob-lems of the population, rather than the number theyrepresent, policy-makers are bound to find themselvesat a loss for solutions once again. Pakistan's leader-ship, it appears, has not evolved in its understandingof population beyond a need to reduce female fertilityand expand family planning services, despite launch-ing a multi-sectoral programme in 1983. Lack oftangible success in reducing growth rates may haveled a more responsive leadership to question whetherit was setting forth on the right quest in the first place.

Endnotes1 Dr Sorayya Jabecn, Managing Director, Family Planning

Association of Pakistan. Interview with author, 1994. All com-ments by her cited in this article are taken from this session. SeeAppendix I for a list of all interviews held by the author in theresearch.

2 See Appendix II for a list of all such major political andlegislative events that have affected Pakistan's population pro-gramme.

3 Wajihuddin Ahmed, Commissioner for Family Planning1971-1973, as interviewed by author, 1994.

4 Similar suspicion of political rhetoric was once expressedeven before Ayub ' s era in a 1956 newspaper editorial: 'As for theargument that the Planning Board set up by Government . . haverecommended the adoption of some sort of check on the popula-tion, this proves only that much that the Government is quite keento shift the blame of our existing poverty from their shoulder tothat of over-population' Gvil and Military Gazette, April 15, 1956.

5 President of the Population Council Dr Frank Notestein sentsome experts in the population field to assist Pakistan. In additionto Dr Balfour, Dr Harper and M r W Parker Mauldin assisted inmaking an appraisal and series of recommendations, which formedthe basis of the national family planning programme as part of theSecond Five-Year Plan (1960-65) (Sharif 1960: 146).

6 Khalil Siddiqui, former Joint Secretary, Ministry for Popula-tion Welfare and first statistician in the 1965 Family PlanningScheme; interview with author, 1994. All comments attributed tohim in this article are taken from this interview.

7 See Appendix HI for budgetary details on family planningfor Five-Year Plans from 1965 to present.

8 Begum Viqar un-Nissa Noon, wife of former Prime MinisterFeroze Khan Noon, was President of Pakistan's Red Cross duringthis period. She recalls noting that Adil 's claims of IUD acceptancewere exorbitant and higher than the retention rate found in herown clinics. When she mentioned this to Muzaffar Ahmed, thenChairman of the Planning Commission, she recalls that he indicatedto her there was nothing he could do about the over-reporting, asAyub Khan was too enamored with the good results of the pro-gramme to entertain any other idea.

9 For a detailed discussion of what became known as 'Waji-huddin 's Approach' see Ahmed (1970) and Robinson (1978). Acritique of its implementation can be found in Robinson et al.(1981).

10 Joseph C Wheeler, Chief of Mission USAJD in Pakistan1969-1977. Correspondence with author, April 4 , 1994.

11 Mubashir Hasan, former Minister, Finance, Planning,Economic Affairs 1971-1974. Interview with author, 1994.

12 Steven Sinding, interview with author, 1994.13 Dr Attiya Inayatullah, current President FPAP. Interviews

with author, January and April 1994. This and all commentsattributed to her arise out of these sessions.

14 The 1993 CDIE draft notes USAID's own views: 'Thefailure of the C M S portion of the program was attributed to theemployment of young, unmarried girls as motivators, the highnumber of political appointees, and die lack of supervision of thefield effort. Inundation was virtually a lost cause because whilecontraceptives were supplied in large numbers to shops, they wereoften kept out of sight. ' (Annex: 8)

13 Interview with author, 1994. This and all comments at-tributed to Dr Mahbub ul-Haq in this article are drawn from thesame interview.

16 Interview with author, 1994. M r Blackton is current Chiefof Mission, USAID Pakistan and Afghanistan.

17 See Robinson (1987) for a more detailed explanation of themulti-sectoral strategy launched during the Sixth Five-Year Plan.

18 Interview with Dr Siraj ul-Haq, Chief of Health and Popula-tion at the Planning Division from 1973-1991, and present WorldBank consultant.

19 Ejaz Naik, former Secretary, Ministry of Planning andDevelopment, interviewed by author. This and all following com-ments attributed to Mr Naik in the report are drawn from the sameinterview.

20 Author ' s interview with Nesim Tumkaaya, Country Direc-tor U N F P A , 1994. All comments attributed to him in this reportare taken from this interview.

21 Obaidur Rob, Population Council in Pakistan, as commentedduring an interview with author, 1994 (see also Cernada and Rob1992).

22 M S Jillani, retired Secretary for Population Welfare, asinterviewed by author.

ReferencesAdil E. 1968. Measurement of family planning progress in

Pakistan. Demography 5(2): 659-65.Adil E. 1969. Pakistan's Family Planning Programme. Paper for

the International Conference on Family Planning, Dacca.Pakistan: Family Planning Division.

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48 Ayesha Khan

Ahmad, Mahbub. 1993. Country paper on achievement/successesof the Population Welfare Programme of Pakistan. RegionalConference on Family Planning, Tehran, September 11-15,1993. unpublished.

Ahmed, Wajihuddin. 1970. Field Structures in Family Planning.Islamabad: Population Planning Council of Pakistan.

Bean LL, Seltzer W. 1968. Couple years of protection and birthsprevented: a methodological examination. Demography 5(2):947-59.

Center for Development Information and Evaluation (CDIE),United States Agency for International Development. 1993.Evaluation of AID Family Planning Programs, Pakistan casestudy. Unpublished draft. Washington DC: CDIE/USAID.

Cernada GP, Rob UAK. 1992. Information, education and com-munication needs in family planning: the case of Pakistan. In-ternational Quarterly of Community Health Education 13(2):97-106.

Civil and Military Gazette, April 15, 1956. Lahore.Coale A, Hoover EG. 1958. Population Growth and Economic

Development in Low-Income Countries. Princeton, USA:Princeton University Press.

Committee Constituted by the Prime Minister. 1975. Report onthe Population Planning Programme. Islamabad: CabinetDivision.

Council of Islamic Ideology (CII). 1984. Report on Family Plan-ning. (Urdu). Islamabad: Council of Islamic Ideology.

Executive Committee of die National Economic Council. 1985.Decision of the ECNEC Meeting held on 5th September, 1985.Islamabad: Government of Pakistan.

Family Planning Division. 1969a. Family Planning Scheme forPakistan during the Fourth Five Year Plan Period, 1970-1975.Islamabad: Government of Pakistan.

Family Planning Division. 1969b. Proceedings of the PakistanInternational Family Planning Conference at Dacca. Karachi:Government of Pakistan.

Finkle JL. 1972. The political environment of population controlin India and Pakistan. In: Clinton R, Flash W, Godwin R (eds)Political Science in Population Studies. Lexington Books.

Government of Pakistan, 1960. Outline of the Second Five YearPlan. Karachi.

Government of Pakistan. 1965. The Third Five Year Plan.Islamabad.

Government of Pakistan, 1970. The Fourth Five Year Plan1970-1975. Islamabad.

Government of Pakistan. 1983. The Fifth Five Year Plan1983-1988. Islamabad.

Government of Pakistan. 1987. The Sixth Five Year Plan1987-1992. Islamabad.

Government of Pakistan. 1988. The Seventh Five Year Plan1988-1993. Islamabad.

Hakim A. 1992. Fertility control in the context of the family andsociety in Pakistan. Canberra: Australian National University.Unpublished PhD thesis.

Hasan M. 1986. Alternative to dependence. Future of South Asia.India: Macmillan Ltd.

MOH, National Steering Committee for Health. 1994. Informalminutes of working group on population welfare. Ministry ofHealth, unpublished.

Jehangir A, Jilani H. 1990. The Hudood Ordinances: A DivineSanction? Lahore: Rhotas Books.

Johnson, Jeffalyn and Associates, Inc. 1981. A Review of UnitedStates Development Assistance to Pakistan 1952-1980. USAID,unpublished.

Khan A. 1994. Summary of CIDA's funding of NGOCC1985-1988. Prepared on basis of CIDA files viewed by author.

Ministry of Health, Labour and Social Welfere. 1965. Family Plan-ning Scheme for Pakistan during the Third Five Year Plan Period1965-1970. Rawalpindi: Government of Pakistan.

Ministry of Planning and Development, Population Welfare Divi-sion. 1983. Population Welfare Programme, Sixth Five YearPlan. Islamabad: Government of Pakistan.

Ministry of Population Welfare. 1992. Foreign assistance re-quirements for Pakistan's Population Welfare Programme duringthe Eighth Five Year Plan. Islamabad: Government of Pakistan.

Ministry of Population Welfare. 1993. Social Action ProgrammeProject (Population) and Population Welfare Programme Pro-ject. Islamabad: World Bank Mission.

Ministry of Population Welfare. 1994. PC-1 Population WelfareProgramme 1993-1998, Federal Activity. Islamabad: Govern-ment of Pakistan.

Myrdal G. 1968. Asia Drama. New York: Pantheon.Notestein FW. 1968. The Population Council and the demographic

crisis of the less developed world. Demography 5 (2): 553-60.Pakistan Family Planning Council. 1969. Annual Report on the

Working of Pakistan's Family Planning Programme 1967-1968.Rawalpindi: Pakistan Family Planning Council.

Pakistan Times, February 25, 1959. Karachi.Planning and Development Division. 1978. Proceedings of the Con-

ference on Role of Field Staff of Population Programme.Islamabad: Government of Pakistan.

Population Technical Assistance Project. 1991. Final Evaluationof the Pakistan Population Welfare Planning Project No.391-0469. Washington DC: USAID.

Ravenholt RT. 1968. The A.I.D. Population and Family Plann-ing Program - Goals, scope and progres. Demography 5(2):561-73.

Robinson WC. 1966. Family planning in Pakistan's Third FiveYear Plan. Pakistan Development Review 6(2): 255-81.

Robinson WC. 1978. Family Planning in Pakistan 1955-1977: areview. Pakistan Development Review xvii (2): 233-47.

Robinson WC. 1987. The "New Beginning" in Pakistan's FamilyPlanning Programme. Pakistan Development Review xxvi (1):107-18.

Robinson WC, Shah MA, Shah NM. 1981. The Family PlanningProgram in Pakistan: what went wrong? International FamilyPlanning Perspectives 7 (3): 85-92.

Rukanuddin AR, Hardee-Cleaveland K. 1992. Can family plan-ning succeed in Pakistan? International Family PlanningPerspectives 18(3): 109-15.

Sen G et al. (eds). 1994. Population Policies Reconsidered: Health,Empowerment and Rights. Harvard Series on Population andInternational Health. Boston: Harvard University Press.

Shah NM. 1979. Past and current contraceptive use in Pakistan.Studies in Family Planning 10(5): 164-73.

Sharif M. 1960. Outlook for government action in family plan-ning in Pakistan, other Asiatic countries and the Middle East.146.

Training, Research and Evaluation Centre (TREQ. n.d. NationalImpact Survey Report. Lahore: Pakistan Population PlanningCouncil.

United Nations. 1969. Report on an Evaluation of the Family Plan-ning Programme of the Government of Pakistan. New York:United Nations Department of Economic and Social Affairs.

United Nations Fund for Population. 1979. Report of Mission onNeeds Assessment for Population Assistance 1979. Islamabad:UNFPA.

United States Agency for International Development. 1982. Pro-ject paper, Pakistan - Population Welfare Planning. WashingtonDC: USAID.

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United States Agency for Internationa] Development/Pakistan.1975. Population planning in Pakistan, unpublished.

World Bank. 1989. Rapid population growth in Pakistan: concernsand consequences. Document of the World Bank, WashingtonDC.

BiographyAyesha Khan is a freelance journalist and researcher based inIslamabad, Pakistan. She was educated at Yale University, USA,and the School of Oriental and African Studies, University of Lon-don, UK. In her writing she focuses on women, health and develop-ment, with a particular emphasis on population and reproductivehealth issues. Her work is published by domestic newspapers andmagazines in Pakistan, as well as foreign news and features ser-vices. Ms Khan contributed to the 1994 Panos, London, bookPrivate Decisions, Public Debate, which was awarded the Popula-tion Institute's XVI Global Media Award for excellence in popula-tion reporting, awarded at the 1995 World Conference on Womenin Beijung.

Correspondence: Ayesha Khan, #8, St. 8, F-8/3, Islamabad,Pakistan.

Appendix 1. List of interviews held

1. Ejaz Naik, former Secretary in Ministry of Planning andDevelopment.January 3, 1994, Islamabad.

2. Mahbub ul-Haq, former Minister for Planning and Develop-ment (1982-86).January 3, 1994, Islamabad.

3. Suraya Jabeen, Managing Director, Family Planning Assoc-iation of Pakistan.January 5, 1994, Lahore.

4. Mubashir Hassan, former Minister for Finance and EconomicAffairs (1972-74).January 5, 1994, Lahore.

5. Attiya Inayatullah, former Advisor for Population to Govern-ment (1980-8) and current President of FPAP.January 11 and April 10, 1994, Islamabad.

6. MS Jillani, former Secretary, Ministry for Population Welfare(1989-91).January 27, 1994, Islamabad.

7. MA Wasey, Project Officer in USAID (1975-93).January 23 and 31, 1994, Islamabad.

8. Zeba Zubeir, former Honorary Chairperson NGOCC(1985-89, 1991-93).February 2, 1994, Karachi.

9. ImtiazKamal, Director of Pathfinder International (Pakistan)and former Secretary, FPAP.February 3, 1994, Karachi.

10. Zarina Fazalbhoy, founder of first family planning clinic inKarachi.February 4, 1994, Karachi.

11. Wajihuddin Ahmed, former Secretary for Population(1971-73).February 2, 4 and 27, 1994, Karachi.

12. Saeeda Waheed, founding member of Family PlanningAssociation.February 24, 1994, Lahore (interviewed by Ruby Bhatti).

13. Steven Sinding, former USAID'Pakistan (1974-78) andpresent Director for Population Sciences, The RockefellerFoundation.February 8, 1994, Cairo.

14. Alamgir Kabir, President Family Planning Association ofBangladesh.March 2, 1994, Dhaka.

15. Andrew Standley, First Secretary, Delegation of the Euro-pean Community.March 10, 1994, Islamabad.

16. Obaidur Rob, Population Council.March 21, 1994, Islamabad.

17. Lady Viqar-un-Nissa Noon, wife of former Prime MinisterFeroze Khan Noon and former President, Pakistan RedCrescent Society.March 24, 1994, Islamabad.

18. DrSiraj ul-Haq, former Chief of Health and Population, Plan-ning Commission, and current consultant to the World Bank.March 31, 1994, Islamabad.

19. Khalil Siddiqi, retired Joint Secretary, Population WelfareDivision.March 31 and April 3, 1994, Islamabad.

20. Baber Hussain arid Lois Bradshaw. Health, Population andNutrition, US AID.April 4 and 7, 1994, Islamabad.

21. Joseph Wheeler, Chief of Mission, USAID Pakistan(1969-1977).Personal correspondence with author, April 4, 1994.

22. Carol Presern, Health and Population Office, OverseasDevelopment Administration (UK).April 7, 1994, Islamabad.

23. John Blackton, Chief of Mission, USAID.April 7, 1994, Islamabad.

24. Wendy Miller, Canadian International Development Agency.April 11, 1994, Islamabad.

25. Nesim Tumkaya, Country Director, UNFPA.April 18, 1994, Islamabad.

Appendix II. List of major political events, legislation, andpolicy developments affecting Pakistan's population programme.

1947 Pakistan's independence.

1953 First volunteer work to provide women with birth con-trol services is begun in Lahore, marking the birth ofthe Family Planning Association of Pakistan.

1955 First Five Year Plan mentions importance of curbingpopulation growth rate to successful economicdevelopment.

1958 Act of Parliament grants Rs.500 000 to Family Plan-ning Association for population activities.

1959 National Family Planning Board established, to intro-duce services. Representatives of FPAP included.

1960 Second Five Year Plan provides Rs.30 million forclinical activities through government outlet.

Limited US aid begins through Population Council.

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50 Ayesha Khan

1961 Muslim Family Laws Ordinances passed grantingwomen unprecedented rights, including requirement thatmarriage, divorce and polygymy be registered withUnion Council. Further, women's grounds for divorcebroadened.

1965 Third Five Year Plan launches first comprehensiveFamily Planning Scheme with separate administrativeinfrastructure for family planning services.

War with India, family planning activities delayed andthen resumed.

1968 Agitation against Ayub Khan's government; religiousparties and Zulfiqar Ali Bhutto's People's Party attackthe population programme as part of campaign.

1969 Ayub is replaced with General Yahya Khan.

1971 Civil war, and East Pakistan becomes newly indepen-dent Bangladesh. During and immediately after the war,all social sector activities are brought to a standstill.

1973 Government is broke, with new President Zulfiqar AliBhutto attempting to re-establish Pakistan's credibilityinternationally and also maintain leftist, non-alignedideology at the same time.

Continuous Motivation System, derived from SialkotExperiment in 1968, extended nation-wide. It is client-based and uses motivation teams for outreach.

1974-77 Contraceptive Inundation is added to CMS reflectingUSAID's conviction that flooding the market with sup-plies will increase contraceptive prevalence.

USAID involvement at highest level yet during thisperiod.

Freeze on USAID April 1976-Sept 1978 due to Islamicbomb crisis.

1977-80 Martial law under General Zia ul-Haq. For three years,field activities of population programme brought to astand-still.

Population Welfare Division brought under Ministryof Health, with Division headed by full Secretary andemployees made full government servants. The pro-gramme is fully federalized.

1979 Hudood Ordinances promulgated, as Islamic punish-ment for certain crimes. These include sex outside ofmarriage and rape. Maximum punishment for these of-fences is death, with conditions that place the onus ofproof of innocence upon the women. These new lawsare considered major setback for women in Pakistan.

Former Prime Minister Zulfiqar Ali Bhutto is tried andexecuted.

US Embassy burned in Pakistan, political turmoil resultsin USAID cut-off again, after brief 6 month resumption.

1980-83 Population Welfare is removed from Ministry of Healthand brought under Ministry of Planning andDevelopment.

Presidential Ordinance issued September 1, 1983 (FieldActivities Act) transferring responsibility for fieldactivities in the population programme to the provinces.

New multi-sectoral strategy is developed, linking familyplanning with health, education, and women's develop-ment activities. Dr Attiya Inayatullah, President ofFamily Planning Association, is made Advisor to thegovernment on population.

CMS disbanded, and family planning staff cut from16 000 to 8500.

USAID resumes in 1982 with a $25 million project forpopulation.

1983 New strategy is launched as part of Fifth Five YearPlan. Programme de-fedcralized, with research, IEC,social marketing of contraceptives, and funding toNGOs as major initiatives.

1985 Dr Mahbub ul-Haq, General Zia's powerful Ministerfor Finance and Planning, enters forefront of populationcampaign. Ban is lifted on publicity for family planning.

NGOCC (Non-Government Organization Co-ordinatingCouncil) begins its function of allocating funds to localNGOs for family planning activities.

USAID internal evaluation results in expansion ofassistance to $73.4 million for population.

1989-90 Benazir Bhutto's elected government draws up plan tofocus family planning in urban centres of Pakistan;health services are required to offer family planningas well.

Ministry of Population Welfare is created.

Qisas and Diyat Ordinance promulgated by PresidentGhulam Ishaque Khan, upon recommendation by theCouncil of Islamic Ideology. It prescribes punishmentsof retribution or compensation for murder. Abortionis included as an act of murder, in which mother andperson who performs the service are culpable.

1991 Nawaz Sharif's elected government appoints BegumAbida Hussain, prominent politician, as Advisor onpopulation. Eight months of strong media publicity,with National Population Conference held and a state-ment by Nawaz Sharif.

Population, along with sanitation, rural development,and female education, is designated a main focus of thegovernment's new Social Action Program, designedwith assistance of the World Bank to integrate andimprove social sector programmes.

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1993

Shariah Bill is passed, a watered-down version of theoriginal version first discussed during General Zia'srule. It brings legal, constitutional, and certain struc-tural changes intended to Islamize Pakistan's social,economic and political system.

USAID announces no forthcoming funds; PresslerAmendment requires US government to cut-offassistance because of Pakistan's nuclear programme.

Benazir Bhutto's newly elected government declarespopulation to be a top priority. It is announced that33 000 lady health visitors will be trained to impartfamily planning and basic health care at the village level.

US aid formally finishes, all funds in the pipeline dryup. Population receives support from the World Bankas part of its assistance to SAP, and the Asian Develop-ment Bank also gives a loan for pan of the Eighth Planproject.

The Eighth Plan includes, as a new initiative in thepopulation programme, a scheme to hire and train12 000 village-based family planning workers for mot-ivation and outreach.

NGOCC mandate expires, MPW and donors disagreeover its level of autonomy and its reconstitution remainspending.

Appendix III. Budgetary allocation and expenditure on Family Planning Programme by Five-Year Plan Period, 1955-present

Years

1955-60

1960-65

1965-70

1970-78

1978-83

1983-88

1988-93

1993-98

Allocation(in

0.5

30.5

284

1028.8

1800

2300

3535

9000

Expendituremillion Rs.)

_

19

356

833.9

617

1686.26

3172.495

% foreignassistance toexpenditure

_

60

18.1

51.3

18.8

52.9

38.6

Utilization

_

62.29

125

81.1

75

82

104

•This figure is a percentage of the amount actually released by the government in its AnnualDevelopment Plans.

Sources:Government of Pakistan (1965, 1970, 1978, 1983, 1988); Hakim (1992); Ministry of Popula-tion Welfare (1992, 1994).

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Policy-making in Pakistan's population programme

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