DOCUMENT RESUME 02863 - [A1993058] Impact of Population Assistance to an Asian Country. ID-77-10; B-156518. Jujy 12, 1977. 48 pp. 6 appendices (7 pp.)} Report to the Congress; by Elmer B. Staats, Comptroller General. Issue Area: International Economic and Military Programs: U.S. Development Assistance Overseas (603,. Contact: International Div. Budget Function: International Affairs: Foreign Economic and Financial Assistance (151). Organization Concerned: Agency for International Development; Department of Defense. Congressional Relevance: House Committee on International Relations; Senate Committee on Foreign Relations; Congress. The population growth rate in Pakistan is one of the highest in the world and constitutes one of the country's most serious problems. Findings/Conclusions: Although about $164 million has been spent on birth cntrol programs since .960, including about $59 million in LU.S. assistance, 1s'istan's rate of growth is still 3%. The social acceptability of large families as well as social and cultural norms of a largely subsistence-level society and the need for greater government support were the chief rogram difficulties. Little attention was paid to the incentves necessary to cause couples to want smaller families. Further, the Agency for International Development (AID) mistakenly assumed that there was a latent demand in the society for family planning services. Recommendations: AID should reassess the advisability of continuing assistance to developing countries (a) which do not have a management system and an information system in existence (or under development) sufficient to reasonably assure that program objectives are being met or (b) whose government and institutions have not demonstrated a willingness to carry out the program. AID should develop and implement additional and innovative approaches to population problems in all the developinq countries through such measures as the AID-sponsored research planned on the determinants of fertility in Pakistan. The contractor's evaluation of the Pakistan program should be disseminated to all contraceptive program officers and used to formulate any program to lower fertility. Greater coordination among volunteer organizations and dopors of population assistance should be encouraged. (DJM) REPORT TO THE CONGRESS BY THE COMPTROLLER GENERAL OF THE UNITED STATES Impact Of Population Assistance To An Asian Country Department of State Agency for International Development More than half the world's people live in Asia, and their number is increasing rapidly. Most Asian countries have programs to slow the population growth rate. This report deals with the program in Pakistan. The high annuai growth rate of about 3 per- cent in Pakistan is one of the country's most serious problems. Growth rate reduction objectives, however, have not been met even though about $164 million has been devoted to the problem since 196C, including about $59 million in U.S. assistance. Program difficulties appear to be the social, economic, and cultural norms of a largely subsistence-level society and the need for greater government support. Lessons learned by he Agency for Inter- national Development in Pakistan can serve as a guide in considering the nature and level of support in other countries. ID-77-,o ID-~~~~~J,177; JULY 12, 1977 COMPTROLER GENERAL OF THE UNITED STATES WASHINGTON, D.C 0548 B-156518 To he President of the Senate and the Speaker of the House of Representatives This is the third in a series of reports on world popu- lation growth, its impact on the quality of life, and pro- grams designed to slow growth rates. This report focuses on an Asian country--Pakistan--and addresses (1) the population situation, (2) interrelationships between population growth and social and economic development, and (3) the effective- ness of population-related activities funded by the Agency for Internaticna Development and others. The report should be helpful to the Congress in consider- ing foreign assistance legislation and in dealing with the is- sues and problems of population, food, and other matters of international significance. Our review was made pursuant to the Budget and Account- ing Ac':, 1921 (31 U.S.C. 53), and the Accounting and Auditing Act of 1950 (31 U.S.C. 67). We are sending copies of this report to the Director, Office of Management and Budget; the Secretary of State; and the Admin'strator, Agency for International Development. Comp troler General of the UnitEd States COMPTROLLER GENERAL'S IMPACT OF POPULATION ASSISTANCE REPORT TO THE CONGRESS TO AN ASIAN COUNTRY Department of State Agency for International Development DI GEST The high population growth rate in develop- ing countries is of concern to the entire world because of its impact on the quality of life of future generations. Rapid popu- lation growth hinders social and economic improvement efforts. The Agency for International Development has provided about $860 million during fiscal years 1965-76 for programs aimed at restrain- ing population growth in developing coun- tries. More than half the oril's people live in Asia, and their number is increasing rapidly. The United States has been a major donor to population program efforts in many Asian countries, having provided country and re- gional project assistance amounting to about $225 million from 1965 to 1976. Most uf these countries have programs to slow population growth. 'ven the best pro- grams, however, face difficult challenges, particularly in countries with large rural populations and high illiteracy rates. (See ch. 1.) GAO reviewed the impact of Agency assist- ance and the problems and restraints en- countered in an Asian country--Pakistan. Its high rate of population growth is one of its most serious problems. Unless the rate is slowed, its 73 million popula- tion will double in 23 ears. (See chs. 1 and 2.) Total population funds for Pakistan from all sources, including the equivalent of $78 million provided by the Government of TearlSb. Upon removal, the report ID-7710 :over date should be noted hereon. i Pakistan and about $59 million by the United States, amounted to over $164 million between fiscal years 1960 and 1916. About $28.5 mil- lion of the U.S. assistance has been for the country's Expanded Population Planning Pro- gram, started in 1973. The expanded program included committing sub- stantially increased resources to a system of visits by motivator teams with potential reproducers and attempting to make contracep- tives more widely available than ever before at a price even the poorest can afford. About half of the U.S. support since 1973 has been for the contraceptive inundation element of the program--a large-scale high- risk contraceptive supply effort based on the assumption hat the major obstacle to the success of earlier family planning efforts was the lack of access by most couples to information and contraceptives. (See ch. 4.) Although family planning efforts have been underway in Pakistan since the early 1950s and significant U.S. assistance has been provided for more than 2 years, the popula- tion growth rate is est.mated at about 3 per- cent annually, still one of the highest in the world. GAO believes the unimpressive results of the expanded program, particularly te in- undation effort, are attributable in part to the Agency's encouraging and entering into the program (1) without adequate assurances of the recipient government's willingness and capability to crry out the program and (2) wiTh little attention to the circumstances that would be neces- sary for potential reproducers to desire smaller families and use family planning services. GAO further believes that the level of the Agency's involvement with the expanded pro- gram since 1973, despite the obvious exis- tence of critical impediments to program ii success, was based principally on the view of its Office of Population in Washington that the supply of family planning services would meet an assumed latent demand and re- sult in actual use of such services. Efforts to reduce or moderate population growth have focused primarily on providing information, motivation, and the delivery of family planning services. Although some benefits were realized, efforts before 1973 were constrained and fell short of goals be- cause of social, economic, and cultural fac- tors; cvil strive; and administrative prob- lems. (See ch. 3.) Earlier management roblems have continued. Specific problems are the lack of (1) ade- quate information on the progress of the program, (2) accountability for contracep- tives, and (3) adequately trained program workers. (See ch. 5.) The Agency had not systematically evaluated the program at the time of GAO's fieldwork in July 1976, and reliable data about pro- gram impact was not otherwise available. However, there were indications that the program was far short of its goal of moti- vating 25 percent of the young fertile couples to use contraceptives by 1978. For example: -- Program data showed the typical acceptor of family planning services to be a woman in her thirties with between four and five children. -- A preliminary report on a 1975 fertility suivey indicated that the percentage of couples using contraceptives wab about the same as reported in 1969. Goverrment of Pakistan commitments for management improvements promised by June 1976 were not met, and the Agency suspended the shipment to Pakistan of oral contra- ceptives in September 1976 and of condoms in November. (See ch. 5.) TeaaL$ WI ~iii The December 1976 report on an Agency- contracted evaluation of the program under- taken in November 1976 noted that the popu- lation planning program in Pakistan is not working and placed responsibility for the program results with the Government of Pak- istan. t stated that available resources must be accompanied by a commitment by the government to population planning goals. The evaluation also identified the socie economic, and cultural norms of a largel. subsistence-level target group as a factor limiting program success. (See ch. .) In a February 1976 report to the Congress, GAO expressed concern about (1) the absence of an inundation feasibility study and (2) the problems of supply and distribution, personnel training, and management infor- mation feedback. GAO recommended that ad- ditional support for the population planning program be obtained from the Government of Pakistan in conjunction with te provision of any additional U.S. funds. (See ch. 5.) The experience in Pakistan illustrates (1) the need for the Agency to have adequate means to monitor and measure the progress of projects to provide for the best use of scarce financial resources and (2) the need for seeking solutions to popula- tion growth problems within the broader context of social and economic change. In many countries, although population growth impldes national development, families view a large number of children as economically and socially beneficial. To increase ad sustain the appeal of family planning, social and economic changes that would make smaller families more attractive should be considered in planning population and development as- sistance projects. For example, proj- ects might seek to provide more education or employment opportunities for women. Although serious problems exist with the program, the Government of Pakistan iv has moved toward innovative and additional approaches by initiating efforts to plan its development projects to affect fertility. The government is also considering incentive projects to promote family planning. In support of approaching population prob- lems in a broader context, Agency officials in Pakistan now require that all new U.S.- supported projects include a population impact statement. The AentM also plans to provide $800,000 for resear . related to methods of encouraging smaller families. (See ch. 6.) Pakistan's recognition of the connection between economic and social development and fertility in its development programs and the Agency's plans to fund research on methods of encouraging smaller fami- lies is consistent with a policy position taken by the Agency in July 1976, which provides that it endeavor to help reduce population growth through developmen t programs that seek to change social ani. economic conditions. On the basis of lessons learned in Pakis- tan, GAO is recommending that the Admin- istrator of the Agency reassess the ad- visability of continuing assistance to developing countries (a) which do not have a management system and an infor- mation system in existence (or actively under development) sufficient to rea- sonably assure that program objectives are being met or b) whose government and institutions have not demonstrated a willingness or capability to carry out the program. GAO is also recommending support of efforts by developing countries to identify, develop, and implement addi- tional and innovative approaches to population problems through such meas- ures as the Agency-sponsored research planned for Pakistan. (See c. 7.) Tear Shlt The nature and extent of future Agency sup- port for the Expanded Population Planning Program in Pakistan is still under considera- tion. The Department of State and the Agency generally agreed with the contents, conclu- sions, and recommendations in this report. The Agency advised that it is reviewing the Pakistan program to identify the issues, re- solve policy questions, dnd develop strategy to guide future U.S. actions. (See ch. 7 and apps. IV and V.) vi Contents DIGEST i CHAPTER THE POPULATION SITUATION IN A SELECTED DEVELOPING COUNTRY IN ASIA 1 Social, economic, and cultural factors foster large families 2 The history of population growth and collection of demcgraphic data 3 Population structure and composition 5 2 POPULATION GROWTH AND THE QUALITY OF LIFE IN PAKISTAN 8 Population increases are outpacing agriculture production 9 Health services facing increasing burden 9 Educational progress impede: 10 Resources and the environment de- teriorating 11 3 PAKISTAN'S FAMILY PLANNING EFFORTS, 1953-70 13 GOP family planning program results 14 Constraints on success of past pro- grams 16 4 CURRENT POPULATION REDUCTION EFFORTS 17 Expanded Population Planning Program 17 Coordination of population assistance 21 5 EXPANDED POPULATION PROGRAM RESULTS 22 Constraints on program success 23 Continued USAID efforts to improve program effectiveness 20 Findings, issues, and recommendations of program evaluation ccOt-ractor 29 6 ADDITIONAL APPROACHES TO REDUCING OR MODERATING POPULATION GROWTH 33 Determinants of fertility 34 CHAPTER Page Efforts to implement development programs based on population and development interrelationships 36 7 CONCLUSIONS, AGENCY COMMENTS AND OUR EVALUATION, AND RECOMMENDATIONS 42 Conclusions 42 Agency comments and our evaluation 44 Recommendations 46 8 SCOPE OF REVIEW 48 APPENDIX I Other donor assistance 49 II Total funding of population assistance efforts in Pakistan--"ll sources, fiscal years 1960-76 57 TII Bureau of the Census projections: impact of population growth 58 IV Letter dated March 16, 1977, from the Auditor General, Agency for Interna- tional Development 61 V Letter dated March 28, 977, from the Deputy Assistant Secretary for Budget and Finance, Department of State 64 VI Principal officials responsible for ad- ministering activities discussed in this report 66 ABLREVIATIONS AID Agency for International Development CMS continuous motivation system GAO General Accounting Office GNP gross natio.,dl product GOP Government of Pakistan IUD intrauterine device USAID U.S. Agency for International Development in Pakistan CHAPTER 1 THE POPULATION SITUATION IN A SELECTED DEVELOPING COUNTRY IN ASIA Over 2 billion people, more than half the world's popu- lation, live in Asia, and the number is increasing rapidly. At current birth rates the Asian population would double in about 35 years. Better health conditions have resulted in a lower mortality rate and a igher population growth rate that has prevented needed improvements and retarded economic and social development. Unlike many less developed countries, most Asian coun- tries have initiated programs to slow population growths To- day 19 have national family planning programs. Most pro- grams are administered by national governments. In several countries--such as Hong Kong, Malaysia, Taiwan, and South Korea--birth rates have reportedly dropped significantly. Family planning programs in Asia have generally encoun- tered less opposition than those in other geographic areas. Even the best programs, however, face difficult challenges, particularly in countries with large rural populations and high illiteracy rates. The United States hs been a major donor, providing about $860 million since 1965 to assist the population pro- grams of developing countries, including about $225 million for hose in Asia. We selected Pakistan for this review because the United States has been assisting the Government of Pakistan (GOP) in its efforts to initiate new approaches to family planning through the country's Expanded Popula- tion Planning Program, started in July 1973. The United States provided about $28.5 million in population assist- ance to Pakistan in fiscal years 1973-76--more than any other donor during the period. Total population funds from all sources, including the equivalent of $78 million pro- vided by the GOP and about $59 million by the United States, amounted to over $164 million between fiscal years 1960 and 1976. Pakistan is a rural, agricultural nation with a popu- lation of about 73 million, making it the ninth most populous country in the world. Agriculture accounts for over 35 percent of its gross national product (GNP) and employs about 57 percent of the country's labor force. 1 The rate of population growth in Pakistan is one of the highest in the world and constitutes one of the country's most serious problems. The rapid increase in population has led to a high dependency ratio and high unemployment and has aggravated shortages of food, health, and educational facilities. Although Pakistan's GNP has increased by nearly 21 percent over the last 4 years, annual population increases of about 3 percent have offset most of these gains and per capita income has remained virtually stagnant. SOCIAL, ECONOMIC, AND CULTURAL FACTORS FOSTER LARGE FAMILIES The social, economic, and cultural setting in Pakistan has changed little since the 1960s and seems to be conducive to large families. One source reporting on Pakistan's family planning efforts during the sixties depicted the Pakistan society as a formidable target group. This source points out that, generally, women marry young and the coming of children is considered an act of God, not subject to man's control; children are often more an economic asset than a liability; and large families are actively desired by men and women. The problem of reducing birth rates in a country with a high illiteracy rate was also noted. A Pakistani researcher recently revisited two villages involved in family planning in the early 1960s and noted a trend toward large families. A family with 9 or 10 children was common, while a family with 5 or 6 children was considered small. Many people he interviewed commented about the satis- faction derived from the presence and growth of children. He reported that all children of agricultural families start contributing to the family after the age of 4. When young, these children take care of goats, buffaloes, and chickens; take food to their father in the field; and do other chores. When they get older, the children earn money by selling milk, working as laborers in the city, working on a horsecart or bullockcart, or helping to get tractors and threshers for the farm or electricity for the irrigation well. The researcher found that unmarried daughters work even more than the sons. They collect cow-dung, cook, take care of the buffaloes, help in harvesting, bring mud from the pond for plastering the house, and do other chores. Socially, when the daughter marries, she provides an extended "small kingdom" to her father, and the son-in-law is a source of social satisfaction. 2 In each village the researcher found two or three trac- tors and a few irrigation wells. He rioted that about all of the families owning a tractor or irrigation well had more than eight or nine children. Fathers told him that one or two of their sons spent most of their time in government of- fices to process applications for tractors, threshers, or electricity. On the other hand, a father with only one or two sons had to leave his work to process the applications, thereby increasing the time and cost involved to obtain these agricultural inputs. THE HISTORY OF POPULATION GROWTH AND COLLECTION OF DEMOGRAPHIC DATA A population count made between 1867 and 1872 was used to establish a base for the first regular census in 1881. The table below shows the-population growth in Pakistan based on censuses from 1901 through 1972. The latest census, made in September 1972, could not be undertaken in 1971 as scheduled because of war. Population Growth in Pakistan, 1901-72 Average annual growth Census_year Population rate between censuses (thousands) (percent) 1901 16,576 - 1911 19,382 1.6 1921 21,109 . 0.8 1931 23,542 1.1 1941 28,282 1.9 1951 33,740 1.8 1961 42,880 2.4 a/1972 64,890 3.6 a/Provisional. According to one source, high mortality was chiefly re- sponsible for limiting Pakistan's population growth from 1901 to 1931. Infant mortality, maternal deaths in childbirth, epidemics, and famines resulted in a death rate estimated at between 30 to 40 per 1,000 persons. The first large increase in Pakistan's population oc- curred during the 1930s. Between 1931 and 1941, Pakistan's annual growth rate went up to almost 2 perceit, adding some 3 4.8 million people to the population. This increase re- portedly reflected advances in the medical field that lowered the death rate to below 30 per 1,000 persons. By 1940, plague was eliminated and mortality by smallpox and cholera was reduced substantially by organized public health efforts and successful vaccination programs. Between 1941 and 1951, Pakistan's population increased by 19.4 percent to nearly 34 million. This increase was attributed to more females (saved from death in infancy during the 1930s) entering their reproductive years. The growth rate continued to rise and reached 3.6 percent, ac- cording to the provisional results of the 1972 census. Available_statistical demographic data As in many developing countries, vital registration statistics are scarce in Pakistan. Statistics on birth, death, and growth rates are derived from censuses and several sample surveys made in the 1960s. However, these sources have limitations and are often considered unreli- able. The 1972 census has only been partially released. Until details are available, only rough estimates of fertility, mortality, and population growth are possible. Provisional statistics indicate an annual growth rate of 3.45 percent between the 1961 and 1972 censuses. Several surveys were made during the 196(s t obtain data on births and deaths. Between 1962 and 1965 a major survey was undertaken to provide current and accurate esti- mates of vital rates and to test a new methodology. This project used two types of independent data collection: (1) a continuous registration of births and deaths and (2) quarterly retrospective surveys which rely on respondents' recall of vital events. These two sources were then com- bined, using a probability formula to estimate missed events, to provide estimates of fertility and mortality. In 1968 a new series of surveys was undertaken which used one system of data collection: retrospective surveys made at various intervals. The following table shows esti- mates of crude birth and death rates and the rate of na- tural growth based on these surveys. 4 Crude Crude Growth birth rate death rate rate Source of estimate (note a) (note b) (note c) 1962-65 surveys: Combined estimate 52 18 3.4 Continuous registration 42 15 2.7 Retrospective surveys 38 11 2.7 1968 survey 36 12 2.4 a/Number of live births per year per 1,000 of population. b/Number of deaths per 1,000 of population. c/Difference between crude birth and crude death rate ex pressed as a percentage. Since these surveys are based on sample estimates, they are subject to sampling errors as well as errors of eporting and coverage. The absence f reliable data has resulted in some controversy as to whoa Pakistan's rate of growth is. Estimates range from 2.5 to 3.7 percent. The GOP's Planning Commission has tentatively adopted a 3-percent growth rate, which is made up of a death rate of 15 per 1,000 and a birth rate of 45 per 1,C00. In 1975 Pakistan participated in the World Fertility Survey program, an international population research program to help countries carry out nationally representative, in- ternationally comparable, and scientifically designed and conducted sample surveys of human fertility behavior. One objective of the Pakistan fertility survey was to provide accurate data on fertility and mortality patterns and levels as well as information on factors affecting fertility. The first report resulting from the survey was published in October 1976. (See p. 33.) POPULATION STRUCTURE AND COMPOSITION The following table shows Pakistan's population by area for selected census years and the rate of growth for each year. 5 Population_by Areafor 1951, 1961, and 1972 Rate of rowth Area 1951 L961 1972 1951-61 1961-72 (millions) (percent) Islamabad area (a) 0.09 0.24 - 8.17 Punjab Province 20.64 25.49 37.37 2.11 3.19 Sind Province 6.13 8.37 13.97 3.11 4.27 North West Fron- tier Province 4.55 5.73 8.40 2.30 3.19 Tribal areas 1.33 1.85 2.51 3.30 2.54 BaluchLstan Prcvince 1.09 1.35 2.41 2.14 4.83 Total Pakistan 33.74 42.88 64.89 2.40 3.45 a/Islamabad was not designated as the capital until 1970. Data not available. Source: GOP statistics. With a total area of 307,374 square miles, Pakistan had a density of 211 persons per square mile based on the 1972 census--72 persons per square mile more than in 1961. Although Pakistan's ropulation is predominately rural, its urban population is growing rapidly. In 1961 the per- centage of urban population was 22.5 percent. Preliminary 1972 census data indicates that the urban population has in- creased to 26 percent and the GOP projected that it would reach almost 30 percent by 1977. The following table shows the trend in the urban-rural population distribution from 1901 to 1972. Urban-Rural Distribution: 1901-72 Percentage _distribution of the epulation Census year Rural Urban 1901 90.2 9.8 1911 91.3 8,7 1921 90.3 9.8 1931 88.2 11.8 1941 85.8 14.2 1951 82.2 17.8 1961 77.5 22.5 1972 74.0 26.0 Souie: GOP Census Organization. 6 Population be- A high percentage of Pakistan's population is young. About 43 percent and 42 percent of the 1951 and 1961 popula- tion, respectively, were under 15 years old. The GOP's Planning Commission estimated that almost 45 percent of the projected 1975 population was under 15 years old. 7 CHAPTER 2 POPULATION GROWTH AND THE QUALITY OF LIFE IN PAKISTAN Rapid population growth in Pakistan has hampered economic development and helped to perpetuate poverty. As Prime Min- ister Zulfiqar Ali Bhutto observed in September 1973: "THE SHADOW OF OVERPOPULATION LOOMS LARGE OVER OUR COUNTRY, indeed over this part of the world. It darkens the prospects of our economic advance. It nullifies our efforts toward social progress. No objective is, therefore, more vital than that of population planning." According to one source, if population growth is checked, Pakistan will have to make tremendous efforts not merely to keep eisting poverty conditions from worsening. Despite more than 25 years of development efforts, improvement in the country's social and economic conditions has been limited. Even if Pakistan can decrease its growth rate, its popu- lation may still double by the bginning of the next century, according to projections preparel by Census on the basis of a yearly growththerate U.S. Bureau of the ranging from 2.5 to 3 percent. Population Year Slow growth Medium growth Rapid growth (millions) i975 69 69 69 1980 80 80 80 1985 91 92 93 1990 104 106 108 1995 118 122 126 2000 132 140 145 2005 147 159 168 Yearly population increases are offsetting uch of Pakistan's economic growth. Despite certain limitations, the concept of per capita income provides some measure of a people's progress and prosperity. Although Pakistan a favorable economic growth rate from 1972 to 1974, its had per capita income remained virtually stagnant and half of the economic growth was consumed by the population increase. POPULATION INCREASES ARE OUTPACING AGRICULTURE PRODUCTION According to GOP statistics, available food grain increased almost 13 percent between 1970-71 and 1974-75. Per capita availability, however, emained about the same because of rapid population growth. Malnutrition continues to be a major problem. The U.S. Agency for International Development in Pakistan (USAID) estimates that 60 percent of Pakistan's population suffers from undernourishment and that 4 million children and mothers are affected by deficiency diseases caused by lack of calories, proteins, vitamins, and minerals and by harmful food habits. Estimates of the minimum nutritional requirements range from 2,350 to 3,000 calories per person per day. The table below shows the average calorie intake for rural and urban areas in Pakistan. Daily Per Capita Calorie Intake in Rural and Urban Areas Average calorie intake Year Rural areas Urban areas 1963-64 1,988 1,731 1968-69 1,974 1,713 1969-70 1,983 1,707 1970-71 1,950 1,734 1971-72 1,898 1,702 Source: GOP statistics. HEALTH SERVICES FACING INCREASING BURDEN Health facilities and workers for Pakistan's 73 million people are scarce and are heavily concentrated in urban areas. USAID estimates that modern health services are available to only 15 percent of the total population and probably only 5 percent of the population in rural areas, where about 75 percent of the people live. The tables below provide statistics on health installations and personnel in Pakistan. Percentage distribution Facility Number Urban Rural Hospitals 548 75 25 Dispensaries 3,086 32 58 Maternity child health centers 715 56 44 Rural health centers 137 1 99 Subcenters of rural health centers 369 - 100 TuberLclosis clinics 92 95 5 Total 4,947 3E 62 Hospital beds 38,033 80 20 Source: GOP Planning Commission. Per capita ratios Category Number Urban Rural Doctors 10,000 1:2,467 1:21,600 Nurses 3,000 1:7,708 1:90,000 Auxiliaries 9,000 1:8,222 1: 8,000 Traditional practitioners 40,000 1:1,850 1: 1,800 Source: USAID estimates. Thus, with a population of 73 million, Pakistan has only 1 doctor for every 7,300 people. In the United States there is 1 doctor for every 600 people. EDUCATIONAL PROGRESS IMPEDED 'he GOP's education policy calls for achieving universal primary education (grades I to V) by 1979 for boys and by 1984 for girls. Although boys' primary school enrollment has more than tripled and girls' enrollment has increased thirteenfold, enrollments have not kept pace with the growth in the school age population. There were more primary school age children out of school in 1)75 than in 1950. 10 Meeting Pakistan's educational goals is a tremendous challenge because --80 percent (about 56 million) of the people are il- literate, --the current level of education expenditures, 1.6 per- cent of the GNP, is one of the lowest in the world; -- there are shortages of equipment and instructional materials and inadequate maintenance of facilities; -- there is a low participation in primary education by girls (only 27 percent of the primary age girls were in school compared with 63 percent of the boys); and --the overall dronnut rate in elementary school between grades I and is about 60 percent, which is considered the greatest barrier to universal primary education. RESOURCES AND THE FNVIRONMENT DETERIORATING According to a USAID report, the environmental impact of population growth in Pakistan can be seen in many places. Arable land is becoming increasingly scarce, and the amount of irrigated land, while increasing somewhat, is not keeping pace with the growing needs of the rapidly expanding popula- tion. From 1901 to 1972 the population of PaKistan quadrupled and population density rose from 53 to 211 people per square mile. Although gross acreage under cultivation increased from over 37 million acres in 1951 to nearly 48 million in 1970 (an increase of 37 percent), the arable land available decreased from 1.35 to 0.99 acres per rural inhabitant during the same period. USAID also reported that erosion and environmental de- gradation are notable in many parts of the country. Forests are virtually unknown outside the mountain areas, and even there they are becoming sparse. Overcutting of timber has greatly increased erosion and downstream silting of he major rivers and reservoirs. Firewood is becoming increasingly scarce and expensive. USAID added that the consequences of rapid population growth can also be seen in Pakistan's cities, such as Karach 11 and Lahore. Raw sewage runs freely in the street. Marginal land inhabited by squatters in usually dry river valleys becomes a breeding ground for disease. According to USAID, an estimated $150 million would be required in Karachi alone to bring water and sewage services up to a minimum standard; that is, to overcome the worst hazards to health. Additional statistical data and projections on popula- tion through the year 2000, as provided by the Bureau of the Census, are included as appendix III. 12 CHAPTER 3 PAKISTAN'S FAMILY PLANNING EFFORTS, 1953-70 Family planning efforts first began in Pakistan when a L .vate voluntary organization, the Family Planning Associa- tion of Pakistan, was formed in 1953. From 1953 to 1970, imily planning activities consisted of four phases: -- The voluntary movement. -- Voluntary activities with government support. -- The first National Family Planning Program, 1960-65. -- The movement's expanded national program during the third Five Year Plan, 1965-70. The Government of Pakistan first supported family plan- r:ng when it budgeted about $105,000 in its first Five Year Plan (1955-60) as a subsidy for the Family Planning Associa- tion of Pakistan. Not until the second Five Year Plan (1960- 65) was an official government family planning program imple- mented. This program, for which the GOP spent about $2.5 mil- lion, had four major goals: -- Provide family planning services to about 10 percent of the married women of childbearing age. -- Establish 3,000 family planning centers in existing health facilities and develop a distribution system for conventional contraceptives. -- Train the required motivational and technical personnel, including 1,200 health personnel (doctors, nurses, health visitors, and midwives) each year. -- Promote rsearch and pilot projects in family planning. This initial government program was administered through the existing health services as a normal function of the government hospitals, dispensaries, and rural clinics. Maternal and child health clinic statf provided counseling and conventional contraceptives--condoms, foam, and jellies. This limited approach proved to be inefficient because the understaffed clinics were overburdened. 13 Under the GOP's third Five Year Plan (1965-70), the family planning program was greatly expanded and expenditures were increased to about $39.2 million. A specific goal was adopted-- to reduce the birth rate from 50 to 40 per 1,000 during the 5-year period--with an ultimate goal of facilitating social and economic development. The GOP hoped to achieve its ob- jectives by getting one-fourth of the fertile population to adopt regular contraception. The tasks under the program basically remained the same as in the earlier effort--education and motivation, provi- sion of clinical services, and distribution o contraceptives. However, the intrauterine device (IUD) was adopted as the main contraceptive device, and family planning services were provided not only through clinics but also through new sources. Personnel other than those in the clinics were brought into the program. Lady family planning visitors were trained as paramedics to ecome the main IUD inserters in the rural areas. Some private doctors were registered to work with the program part time or full time. In addition, the traditional village midwives (dais) were recruited to motivate couples, distribute conventional contraceptives, and take women to clinics for IUD insertions. Toward the end of 1968, the pro- gram employed about 40,000 people on a regular basis. In addition, a variety of mass media wtas used to inform the public about family planning. Conventional contraceptives were offered at minimal prices through program distributors. Those who agreed to steriliza- tion were compensated for loss of wages during convalescence. Other incentives, in the form of bonuses, were offered to medical paramedical personnel for sterilization, IUD in- sertions, and referrals for sterilizations. From 1960 through 1970, when Pakistan included East Pakistan (now Bangladesh), about $83.4 million was spent on the GOP's population control efforts. The Agency for Interna- tional Development (AID) provided local currency support throughout the period and dollar support for advisory, train- ing, and commodity inputs during the latter half o_ the period. GOP FAMILY PLANNING PROGRAM RESULTS Two evaluations were made of the COP's family planning program in effect during the 1965-70 period. One was a study by a joint United Nations/World Health Organization Advisory Mission; the other, entitled "National Impact Sur- vey Report," was made by the Pakistan PFmily Planning 14 Council with the assistance of a number of other Pakistani and foreign organizations. Both studies, made in 1968-1969, (before the 1965-1970 program was complete), concluded that some progress had been made under the program but that the overall goal of reducing the birth rate had not been achieved. The GOP had hoped to achieve the birth reduction target by motivating one-fourth ot the fertile population to adopt regular contraception. However, the National Impact Survey, based on interviews of over 6,700 married women, determined that only about 9 percent of those surveyed had ever used contraceptives and that about 6 percent were current users. Further, the findings suggested that the program had reached mainly older women who did not desire more children and that the lack of acceptance of birth control among younger women with few children minimized the potential demographic impact of the program. The U.N. study made basically the same point. The U.N. study pointed out that nothing comrarable to the GOP's ambitious target of reducing the birtn rate from an estimated 50 tc 40 per 1,000 between 1965 and 1970 had been achieved by government action in any large country with a mostly illiterate population such as Pakistan. According to the study, achieving the numerical target is not the only measure of a program's success. Progress must also be measured in terms of (1) the establishment of a good organiza- tion with a functioning supply system, which will make family planning a matter of respectability, and (2) the widespread knowledge and accepted practice of family planning. In this respect the U.N. study indicated that some success had been achieved. ApLrt from the establishment of a program and the development of an actual organization, staffing, and procedures, the study noted that a major pro- gram achievement was in informing the people about family planning and its importance and in making the subject a mat- ter for public discussion. This achievement was confirmed by the National Impact Survey, which found that 77 percent of the Pakistani wives interviewed claimed knowledge of at least one method of family planning. owever, 25 percent made negative statements about the program. Both the U.N. study and the National Impact Survey recog- nized that knowledge and availablility of contraceptives alone may not insure their use. The U.N. study stated that, al- though knowledge and availability of contraceptives were pre- requisites to use, people also had to become determined to restrict the size of their family. 15 The National Impact Survey concluded that, because con- traceptive use rates were found to be quite low, it would seem that mere knowledge of a method is not sufficient condi- tion for use. The survey also concluded that there would not appear to be a significant number of people willing to accept family planning after being exposed to information on contraceptives. The U.N. study noted, however, that this aspect did not detract from the importance and urgency of proceeding with the program, because even partial fulfill- ment of program goals would be a considerable achievement. CONSTRAINTS ON SUCCESS OF PAST PROGRAMS Constraints on the success of the family planning program appear to fall into at least two basic cateaories: (1) social, economical, and cultural factors and (2) problems with the program. One source noted that the social, economic, and cultural conditions in Pakistan during the 1960s did not appear to foster the type of rapid behavioral change implied in the government's goal of inducing widespread acceptance of con- traception and substantially reducing fertility. Some of the constraints in Pakistan were summarized as follows: "* * * a predominantly agricultural society, the existence of high mortality with its presumed influence on continued high fertility and couples' desire for security through their children in old age; cultural values emphasiz- ing differential preference for sons; and pre- valence of fatalistic beliefs." Several problems reportedly surfaced within the program. The mostly illiterate village midwife was reportedly a poor field motivator and distributor. The ID came into disrepute after repeated occurLences of bleeding, often after improper or unhygenic insertion, and the lack of followup services. Other program areas that the U.N. study said needed to be improved included: organization and administration, family planning and health services (medical), motivation and promotion of family planning (communication/publicity/ education), training for personnel, evaluation and research (need for basic reliable data), and supplies and transport. 16 CHAPTER 4 CURRENT POPULATION REDUCTION EFFORTS Major changes were programed for the family planning effort for 1970-75. However, family planning efforts were interrupted from 1969 to 1972 because of a change in the political situation and the civil war which led to the secession of East Pakistan and the formation of Bangladesh. During this period the family planning program reportedly suffered from lack of attention from central and provincial governments, and in 1972 donor assistance was almost totally cut off. EXPANDED POPULATION PLANNING PROGRAM In May 1972 the Prime Minister took action which resulted in a scheme that was to continue initially for a period of 5 years, or until 1978. However, preliminary results of the 1972 census, which indicated that Pakistan's population ex- plosion was continuing, resulted in a major restructuring of the program. This effort, begun in July 1973, is generally referred to as the Expanded Population Planning Program to reflect a wider development-oriented approach. The ultimate goal of the expanded program is to reduce the crude birth rate from an estimated 45 per 1,000 to 35 per 1,000 by the end of the 5-year period (1978). To achieve this goal, it was estimated that at least 16 percent of all eligible couples and 25 percent of the young fertile couples would have to be motivated to use contraceptives by 1978. Major features of the program which differ from past efforts include a system of continuous motivation, efforts to make contraceptives widely available at a price even the poorest can afford, and establishment of an organization to devise national policy options to promote small families (referred to as beyond family planning measures). Steps were also taken in 1975 to expand the availability of steriliza- tion services. The GOP has financed about 34.9 percent of the total current program expenditures from fiscal year 1974 through 1976. Although GOP funding has steadily increased since fiscal year 1973, its support as a percentage of the total GOP budget, excluding foreign assistance, steadily decreased each year until fiscal year 1976, as shown on the following page. 17 GOP Support of the P lation Control Effort GOP budget Percentage of support for GOP budget Fiscal population allocated to year program population program (millions) 1973 $2.4 0.22 1974 3.5 .20 1975 4.0 .18 1976 7.6 .31 U.S. assistance for the program amounted to about $20 million in fiscal years 1973-75. An additional $8.6 mil- lion in assistance was planned in fiscal year 1976. It is estimated that the last contribution date for this effort under current agreements will be September 1978. Assistance by other donors is discussed in appendix I. U.S. Assistance, Fiscal Years 1973-76 1976 Cost component FY 1973-75 (note a) Contraceptives (centrally funded) $ 9,687,000 $ 5,100,000 Local currency 5,000,000 3,000,000 Other costs (note b) 2,856,565 - Commodities (excludes contraceptives) 2,439,000 437,000 Participants 16,600 29,600 Contract services 1,283 - $20,000,448 $ 8,566,600 Total $2d,567,048 a/Planning figures (expect for participants, which is actual). b/Dollars provided in the first project agreement to offset local currency costs. 18 The U.S. assistance has supported all aspects of the program, including the continuous motivation system (CMS) and management improvements in (1) contraceptive supply and distribution, (2) manpower and training, (3) project data feedback, (4) publicity and communications, and (5) automotive fleet operation and maintenance. Continuous motivation Under CMS a smaller number of trained male-female teams replace the dais (village midwives) as front-line workers. The system serves the more densely populated areas which contain 74 percent of Pakistan's population. Each team covers an administrative area with a population of about 12,000. Under the system, each team is to contact eligible couples (married fertile couples of childbearing age) four times a year to promote acceptance and regular use of some form of family planning, to distribute contraceptives, and to obtain information on the couples. To serve the less populated areas, a mobile-clinic- based approach (referred to as non-CMS) was designed, under which one population planning officer with two mobile teams would be assigned for each 100,000 people. Each mobile team, operating from a clinic, was to have a male and a female para- medical worker. Contraceptive inundation The concept of contraceptive inundation, which involves making contraceptives abundantly available at a price even the poorest can afford, was incorporated into the program in fiscal year 1974. The concept, as developed by AID officials and adopted by the GOP, is based on the assumption that a major problem in earlier family planning efforts was the lack of access by most couples to the information and means necessary to limit their fertility. The effort also has been described as a test of a hypothesis that the wide- spread availability will result in the widespread adoption of family planning. Under the inundation effort, predetermined quantities of oral contraceptives and condoms were to be supplied to 50,000 recail oulets; 2,000 participating practitioners; and 1,650 participating hospitals, clinics, and dispensaries. The effort also required that an additional 12-month supply of contraceptives be in the country. These quantities determined based on optimistic projections of increased were use--not on actual demand. A 50-percent safety factor for 19 oral contraceptives was added to the predetermined quantities and the 12-month supply to insure adequate supplies for cal- endar years 1975-77. Contraceptives are also distributed by the male-female teams established under CMS and non-CMS. The official price of 2-1/2 cents for a 1-month supply is supposed to be ap- plicable to contraceptives distributed through all sources of supply except medical doctors and hospital clinics, which may distribute oral contraceptives free. AID mission officials said that they do not regard in- undation as the test of hypothesis or as an experiment. They view contraceptive inundation as nothing more than as- suring that plentiful supplies of conventional contraceptives are available to satisfy projected demand over the life of the project. The Director, USAID, stated that the success or failure of inundation would be determined simply by measuring whether or not specified supply goals have been achieved. According to the Director, the entire Expanded Population Planning Program represents a test, of which inundation is one of the factors. The test is whether the widespread avail-- ability of family planning services (including contraceptive supplies, octivational efforts, and counseling) will lead to the widespread use of contraceptives and a consequent decline in the birth rate. Beyond family planning Although contraceptive supplies and services are an essential component of population programs, they were not in themselves considered sufficient to solve population prob- lems. It was felt that typical family planning services had to be supplemented with national policy options so that influences from all directions are exerted upon the individual toward developing small family norms. The GOP, therefore, established a Demographic Policy and Action Research Center within the Population Planning Council, under the Ministry of Health, Labor, Manpower, and Population Planning. The research center was to -- analyze the national policies in public development sectors in relation to their family size bias, -- consider elements to be introduced into public sectors which have some bearing on population policies, 20 -- launch innovative experiments to accelerate acceptance of population planning practices, and -- make efforts to create population biases in publ'c sectors by demonstrating experiment results for an ultimate integrated population policy. COORDINATION OF POPULATION ASSISTANCE The United States and six other donor countries, six private international organizations, and one intergovernmental organization have provided family planning and population assistance to Pakistan. U.S. assistance that exceeds the scope of the inundation effort is discussed beginning on page 33. Assistance by other donors is discussed in appendix I. The Aid-to-Pakistan Conso-:tium, chaired by the Interna- tional Bank for Reconstruction and Development (World Bank), coordinates all economic assistance to Pakistan. Consortium members and Pakistani representatives meet annually in Paris to discuss the world economic situation and Pakistan's cur- rent problems as reported by the World Bank. USAID believes these meetings have helped to create an awareness of the population issue when developing policies for Pakistan. In addition to the Consortium, all donors and potential donors to the GOP population program are invited to attend the annual donors' meeting, which is convened by the GOP in Islamabad. Quarterly meetings of major donors which are represented in the country with the government are held to coordinate assistance and to keep donors apprised of progress, prob'.ems, and issues. A USAID official felt that coordina- tir,n among donors was adequate and that there is no overlap- ping of assistance since each donor has identified its area of interest. Currently, the Association for Voluntary Sterilization, Family Planning International Assistance, and the Family Plan- ning Association of Pakistan do not participate in any of the donor assistance meetings. The first two associations do not have representatives in Pakistan. The Family Planning Associa- tion of Pakistan, although invited, has not attended any recent meetings. A USAID official felt it would be beneficial if rep- resentatives from these organizations could attend. The mat- ter of donor coordination was also addressed in the-contract evaluation of the program in Pakistan. (See p. 32.) 21 CHAPTER 5 EXPANDED POPULATION PROGRAM RSULTS No systemat. ,aluation of the current program's impact had een made by the time of our review in July 1976. How- ever, a contract review of the entire program was completed in December 1976. (See p. 29.) A GOP planning document noted that assessing any fer- tility reduction is difficult because of the absence of a reliable vital registration system or an ongoing sampling project for estimating vital rates during past years. The absence of adequate reliable data from these and other sources has hampered not only measurement of any fertility reduction, but also measurement of shorter term indicators of achievement, such as the number of acceptors and users. However, information that was available during our review permits some insight into the program's progress. There are many indications that progress under the GOP's expanded program has not been impressive. For example: -- Under the program, young couples were targeted as those who would have to be reached to significantly affect the fertility rate. However, a high percent- age of this target group has not been accepting family planning. Data in the following table reveals that, on the average, women participating in the program during 1975 were in their early to middle thirties and already had between four and five children. 1975 quarterly data (note a) Flrst Second Third Fourth Median age of client 35.0 34.2 33.5 33.5 Median number of living children 4.6 4.6 4.5 4.5 a/Data taken from a client information system which was implemented by the GOP in February 1975. The system had only been implemented in 11 of 40 proj- ect areas, and the above data is for 7 of these project areas. Only about 20 percent of the women in the program were said to be within the age and parity group of the tar- get population (women under 30 with less than four children) which must be reached to significantly affect fertility. 22 -- The preliminary results of the 1975 fertility survey indicated that the percentage of couples using contra- ceptives had remained about the same as found during a 1968-69 survey. The report on the survey, released in October 1976, showed that only 5 percent of the cu:rertly married, nonpregnant women were using contra- ceptives or had been sterilized. -- The widespread availability of oral contraceptives and condoms was intended to increase demand for them and thus contribute to the adoption of fily planning. The program is based on the assumption that the major inhibition to success in earlier fily planning ef- forts was the lack of access by most couples to the information and means necessary to limit their fertil- ity. Although the GOP reported an initial increase in quantities distributed to acceptors, USAID determined that an unknown portion of the contraceptives went not to acceptors, but to stock outlets. The contraceptives which did go to acceptors went primarily to those with a higher age and large family. This suggests not an increase in demand for services, but the fulfilling of the needs of an already existing demand. -- A Pakistani researcher involved in the promotion of family planning during the early 1960s recently re- ported on his observations relating to the practice of fnily planning in villages he revisited during mid-1976. He observed that although the general level of knowledge of family planning was very high, the level of the practice was not--only 1 out of every 20 people he talked with reported using contraceptives for a reasonable length of time. He attributed the low percentage of Pakistanis practicing family plan- ning to the social, economic, and psychological bene- fits of children. For example, he said that more "hands" arn more and cited the position of a mason with five sons who earned more than three times the daily wage of his colleague who has only one son. (See also pp. 2, 3, and 28.) CONSTRAINTS ON PROGRAM SUCCESS Many problems with the expanded program may be contribut- ing to the unimpressive results. CMS does not appear to be functioning as initially perceived, there are problems with supply and distribution under the inundation concept, and man- agement improvements--including those in personnel training and management information feedback--are behind schedule. 23 Organizational factors and continued cultural and economic resistance to family planning may also be hampering the pro- gram's progress. In an earlier report o the Congress, 1/ we expressed concern about the problems of supply and distribution, per- sonnel training, and management information feedback. In that report we also said "For the past several years AID has concentrated primarily on supplying contraceptive devices, on the assumption that, if adequate contraceptive supplies were available, at affordable prices, people would use them. AID is continuing this type of program in Pakistan with its plan to in- undate the country with contraceptives. Merely supplying the means to control the birthrate, however, is not necessarily sufficient to solve the problem of escalating population growth rates." Problems with the Continuous Motivation System Under CMS, trained male-female teams are to visit eli- gible couples three or four times a year to motivate them to use some method of family planning, deliver contraceptives, and collect vital statistics. The GOP believed the system would be an improvement over prior efforts. However, USAID officials indicated that CMS has not been as effective as envisioned. Examples of the problems experienced with CMS include: -- The inability to recruit workers--especially females-- with the desired level of education. -- The ineffectiveness of the male members of the motiva- tor teams. The male member of each team was to con- tact the male in each household; however, because the males were usually not at home during the day, the male team member was relatively ineffective. A change in his function was being formulated during our review. L/"U.S. Assistance to Pakistan Should Be Reassessed," ID-76-36, Feb. 6, 1976. 24 -- The team's inability or unwillingness to make the prescribed number of visits to eligible couples. The recently issued report on the 1975 fertility survey showed that only 29 percent of all ever married re- spondents reporteo having had contact with a family planning worker while 71 percent had had no contact. One district oficer doubted his field workers could reach many couples regularly because the district is mountainous and villages and couples are scattered. The lack of adequate transportation contributed to the problem. -- Indications of inadequate training in some areas. --Poor supervision. -- The GOP's frequent late release of funds for salaries and other costs. Another problem which may be lessening the effectiveness of the field workers concerns the fact that they generally are not residents of the villages they visit. A village leader we talked with said that the government's workers had not been successful in motivating village residents because the workers were outsiders who spoke and dressed differently from the villagers. He said that, since the workers are not village residents, villagers are reluctant t discuss a sub- ject as sensitive as family planning with them. Contraceptive inundation Contraceptive inundation was initiated i Pakistan, in conjunction with the CMS effort, to make condoms and oral contraceptives widely available at a price even the poorest could afford. The effort has made these contraceptives more widely available than ever before; however, many problems have been encountered ir implementing the concept. The Area Auditor General reported in January 1976 that the lack of an efficient supply and distribution control system and adequate storage facilities contributed to stock overages and shortages at many population, planning offices. The report pointed out that, until the new Contraceptive Logistic Information System is in operation. it would not be possible to adequately equate the need for contraceptives with the massive distribution throughout Pakistan. 25 We also discussed inundation in our earlier report. 1/ We noted that no comprehensive analysis was made beforehand to determine the effect of inundating Pakistan. At that time USNID officials said that the population problem was too acute to wait for a study of this magnitude and that inundation in Pakistan was a high-risk project which might be a test case for other countries. Because of the lack of reliable information on contra- ceptive distribution (and use), USAID assigned three local national employees to make field trips and monitor the flow of contraceptives. These individuals were drawn from the staff of end-use monitors who follow all AID-funded commodities. Information obtained on the fisld trips indicates that: --Although inundation levels of contraceptives have been available in Pakistan since November 1974, many outlets still do not have what are considered inunda- tion stock levels. -- Many retail concerns reported as outlets do not exist or have ceased operation; in August 1975 the GOP re- ported that there were 33,233 of these outlets; how- ever, based on a sample, USAID projected that there may have been only about 13,500. -- Some commercial outlets have had the same supplies on nand for from 2 to 3 years. --Some commercial outlets refuse to accept contracep- tives for sale or will not accept what are considered inundation levels, noting the lack of demand. USAID officials informed us that the low profit margin is another factor. --Although the influx of contraceptives has generally brought the price down, in many cases prices are still above those stipulated under the program. Management improvements behind schedule When the program was begun in 1973, the GOP agreed with AID to make several management improvements with particular emphasis on (1) project data feedback, (2) contraceptive supply and distribution, (3) automotive fleet operation and 1/See note, p. 24. 26 maintenance, (4) manpower and training, and (5) publicity and communications. As of June 30, 1976, the GOP was behind schedule in implementing improvements in three of these areas, and evaluations of improvements in the other two areas had not been made available to USAID. The implementation of an information feedback system is considered - _,,tial to effective program management and measurement Ad goal achievement. Although the GOP agreed in mid-1973 to install a Client Record System, as of July 1976 such a system had not been fully implemented. Data was being collected and reported in only 11 of 40 project areas, and two other portions of the system had not been implemented at all: (1) a system for validating reported information and (2) a system for feeding back information to reporting areas. As a result, systematically developed data is not available on the program's impact nationwide, USAI officials have little confidence in most of the data reported, and evalua- tion of the program's impact through this means is severely restricted. The GOP considers the information system to be in the testing stage. The lack of accountability for contraceptives has con- ti ually plagued the program. The problem is compounded by the inundation levels of contraceptives supplied by the United States and other donors. To remedy the problem, an Information System of Contraceptive Movement was to be opera- tional throughout Pakistan by September 1975. This system was to measure the issue and receipt of contraceptives be- tween all program distribution points and to measure inven- tories at each level of program operation. However, in July 1976 the system was still in the testing stage. Deadlines in three other management areas--automotive maintenance, manpower arn training, and publicity and communications--have also not oeen met. The percentage of inoperable vehicles has not been reduced to the planned level, and evaluations of efforts in the other two areas are way past due. Organizational problems The organizational level and structure of the family planning organization may also have contributed to the un- impressive program results. The progranl, which is under tne Ministry of Labor, Manpower, Health, and Population Planning, is administered by a Population Planning Council, with decisionmaking divided between the federal and provincial governments. USAID believed that the organizational location 27 and structure tended to place the program at a relatively low level, which gave its leaders limited access to top Pakistani administrative and political decisionmakers and made the program somewhat less visible to these decision- makers. Organizational changes were being initiated in mid-1976. The population planning organization is still under the same ministry, but the top position in the organization has been elevated from a Joint Secretary to a full Secretary. USAID officials were not sure what impact these changes might have. Resistance to family planning efforts USAID reports that, despite a widespread consensus among the masses and the elite on the legitimacy of population plan- ning, there remains a religious and cultural resistance to modern contraceptive practice among many couples, especially in rural areas. Even though Islamic scholars have declared that Islam and family planning are not inconsistent, some religious resistance still exists. According to a USAID report, this attitude does not reflect an opposition to family planning as much as a general cultural resistance to any modern innovations. A Pakistani researcher who is concerned with the way people perceive innovation told us that he found in his visits to rural villages in Pakistan that family planning is considered unacceptable and that the existing social, politi- cal, and economic structure spports large families. This researcher believed that to most rural people, the rationale for limiting family size is inadequate. Given the existing perceptions regarding the value of children, the practice of family planning would be considered irrational behavior. (See also pp. 2, 3, and 23.) He believes agricultural innovations are more easily accepted because they are consistent with existing norms and values. On the encouraging side, however, the recently issued first report on the 1975 fertility survey showed that 49 percent of the marriad fertile women said that they did not want another child. CONTINUED USAID EFFORTS TO IMPROVE PROGRAM EFFECTIVENESS In May 1976, USAID and the GOP entered into an agreement which, as in prior agreements, included target dates for com- pletion of various management improvement objectives. This agreement differed from prior efforts, however, in that USAID reserved the right to withhold delivery of contraceptives if cer' Ain target dates were not met. 28 According to a USAID official, the GOP did not meet the June 1976 target dates established for improvements in the areas of contraceptive supply and delivery, the information feedback system, organization, communication/motivation, the national sterilization program, and transport. The United States suspended deliveries of oral contraceptives in Septem- ber 1976 and deliveries of condoms in November 1976. Deliv- eries were suspended not only because certain agreement provisions were not met, but because of an apparent contra- ceptive oversupply in Pakistan. USAID officials are prepared to resume deliveries as soon as important agreement provisions are met and the need for new supplies has been established. Based on distribution figures for the 6-month period ended January 31, 1977, however, a 26-month supply of condoms and a 44-month supply of oral contraceptives were on hand. In May 1976 USAID and the GOP also agreed to coope- rate in making an evaluation of the program which would provide sufficiently firm conclusions to facilitate agreement on the nature and shape? of any future USAID assistance. FINDINGS, ISSUES, AND RECOMMENDATIONS OF PROGRAM EVALUATION CONTRACTOR The evaluation agreed to by USAID and the GOP was made under an AID contract and work in Pakistan was started in November 1976. Under the contract an evaluation team was to: "Evaluate the Pakistan Expanded Population Pro- gram in order to assess its results in achieving the program goal of a rapid and sustained decline in the rate of natural population growth through the establishment and implementation of a family planning program capable of widespread delivery of contraceptive measures and promoting of and counselling on contraceptive use. The evaluation also should include an assessment of the reasons for success or failure of the program to attain its goal, the roles of the U.S. and other donors in the Pakistan program and the evaluation team should develop such recommendations for changes in the Pakistan program as may seem to be appro- priately designed to improve program effectiveness and suggestions on the future role of donors in supporting or assisting the Pakistan program." The evaluation was completed and a report published in December 1976. In general, the evaluation team's observations were consistent with the conditions found during our review. 29 Evaluation indicates ineffective program The evaluation team reported that he population planning program in Pakistan is not working. The team's findings in- cluded the following important indicators, derived from anal- ysis of available data and field visits. -- Only about 8 percent of the target female group was actually practicing family planning. (This was roughly the same or slightly higher than was believed to be practicing in 1968-69 (about 6 percent).) --The number of oral contraceptives distributed had dropped below 400,000 cycles per month beginning in early 1976 and condom distribution had remained essentially static. -- New acceptor rates in clinics visited by the re- searchers were minimal and the monthly number of rew IUD acceptors had not changed iiauch over the past year. The team also noted that, overall, there are no marked trends in birth or fertility rates. The report discusses a number of management problems that were identified as hindering accomplishment of the pro- gram's objective. These problems include poor management of resources (although the quantity of resources are judged to be adequate), the absence of a coordinated logistics system, questionable characteristics (for example, inexperienced, young unmarried, and nonresident) of personnel on the field motivation tams, a motivation message perceived as irrele- vant, and the failure to use private sector expertise. Issues facing the program Several issues noted in the evaluation report merit in- depth consideration by AID and the GOP. The evaluation team's characterization of the program as "an inadequate response to weak signals from the Federal government; national, elitist values at variance with the prevailing norms of a semifeudal agricultural society" expresses the essence of these issues. Brief descriptions of these important issues, as seen by the evaluation team, are presented below. 30 Population olicy--Questions are being raised about the program's effect on fertility and its capacity to affect fertility. Some questions concern the appropriateness of national fertility goals for people living in semi- feudal, subsistence-level conditions and the validity of the assumptions that (1) national social values are shared by the largely illiterate population and (2) the people identify traditional social norms with national aspirations. The report points out that policymakers are concerned with increasing production of foodstuffs, cotton, and export labor to earn critically needed for- eign exchange. The people in the rural areas are being asked to increase agricultural production while reducing the number of cnildren per family. Yet, historically the former goal has been accomplished by increasing the number of children. The position of national leadership--The population pro- gram policy alternatives considered have been limited to those on which a sufficient political consensus exists to provide a basis for action. The Prime Minister ap- parently supports the program, and some people hope that a strong, visible expression of support by him will help the program. However, there is conservative opposition to the program based on a feeling that military strength and manpower development are more important to Pakistan. (This opposition could be strong enough to make the Prime Minister cautious about expressing his views before an election.) A mcre fundamental problem is the national leadership's narrow perception of the program as solely a government responsibility. The placement of the popu- lation planning authority within a single ministry-- which has adhered to strict compartmentalization of program responsibilities--has inhibited implementation of a broader, multisectoral approach. Village socio-economic dynamics and family tlannin strategie--The evaluation team noted that for many rural areas, population control efforts may represent "seed on stony ground" for a long time. The cost of children is low. For example, education is purely local and minimal, with no out-of-pocket expenses involved; pregnancy, birth, and infant care are totally household functions and almost free; children have no special diet and eat last in the household; and frequent pregnancies are not inconsistent with female work routines. Further- more, children work at very early ages. Where land is limited, applying more labor per unit of lanc to increase yields is a primary method of raising output. Children 31 are also the only real way to store capital for the future, either for economic security or future produc- tion. Also, in some cases they are a source of physical security. The evaluation report also discusses two other issues: the questionable management expertise involved in the pgram and the appropriate style and magnitude of U.S. development assistance. Recommendations for proigram_mprovement The -evaluation report contains a number of interrelated recommendations to improve the program. Among the more im- portant of these, in cur view, are the following: -- The Prime Minister should (1) call for the formulation of policies to insure interministerial support and co- operation for reduced fertility rates and (2) desig- nate accountability throughout the administrative structure of the government for program compliance. -- AID should proceed with the current proposal for creat- ing a population r search and development project to selectively enlist community support in the develop- ment and implementation of well-planned innovative programs to encourage small families. (See p. 41.) --AID should supply contraceptives as demand and reason- able supply levels warrant. Other recommendations deal with (1) the GOP organiza- tional structure and staffing and (2) actions it could take to improve training, and broaden cooperation and collabora- tion of other public and private groups. Recommendations for donor agencies concern improved coordination and collabora- tion and a decreasing leadership role for AID. 32 CHAPTER 6 ADDITIONAL APPROACHES TO REDUCING OR MODERATING POPULATION GROWTH The proportion of Pakistani couples presently practicing family planning does not appear large enough to bring about major declines in fertility. The apparent limited effective- ness and impact of Pakistan's family planning program indicate that additional measures should be taken to make family plan- ning more appealing to more couples and to sustain increase in the effective practice of contraception a long-term and fer- tility control. This need was recognized by the government in the ex- panded program, which adopted a wider development-oriented approach. A Demographic Policy and Action Research Center was established to explore national policy options that would encourage smaller families. Research is planned on ways to increase the demand for family planning services. Pakistan participated in the World Fertility Survey program in 1975. The survey is an AID-supported international population research program to help countries carry out na- tionally representative, internationally comparable, and scientifically designed and conducted sample surveys of human fertility behavior. The Pakistan Fertility Survey should be useful to policymakers in Pakistan in considering alternative approaches to reducing or moderating population growth because it was designed to meet their specific information needs. The survey is also intended to -- furnish accurate data on patterns of fertility and infant/child mortality; --make analyses of fertility possible in relation to female education, female employment, and infant/child mortality; -- furnish reliable information about the evaluation of the effect of the family planning program; and -- help measure changes in fertility since 1968. Survey fieldwork included interviewing about 5,000 randomly selected women and compiling information on 4,893 households. The response rate was over 90 percent. first report resulting from the survey was The published in 33 October 1976. (Some highlights of the report are described on pp. 23, 25, and 28.) DETERMINANTS OF FERTILITY To devise policies and programs for reducing population growth, a country must have reliable scientific information on the factors affecting fertility behavior. Authorities seem to agree that more information is needed about the de- terminants of fertility in Pakistan and ways to most effec- tively influence fertility through social and economic change. Conclusions regarding fertility determinants must therefore be based on research studies made in other countries and on the limited data available in Pakistan. Based on studies made throughout the world, four variables have been identified as having apparently the strongest im- pact on fertility: (1) level and distribution of income, (2) the employment of women, (3) the educational level of women, and (4) the rate of infant and child mortality. Although research on these factors in Pakistan is sparse, their rel- evance to the situation is considered possible. Income A numbei of studies h_ve shown that, at very low income levels, fertility tends to rise as income begins to rise. Couples may perceive that at higher levels of income, they can afford to raise more childrei. Conversely, very poor families may be so malnourished that they are unable to have as many children as they want because females may be less fertile. However, at a certain point, as income continues to rise, the desire for additional children begins to decline. At higher income levels people may begin to substitute the quality of children (that is, through improved availability of health, education, and related services) for quantity. This hypothesis was confirmed somewhat by a study in Pakistan which found that, the more satisfaction a Pakistani couple expresses about its income level, the less desire it will have for children. Female education A study in Pakistan found that better educated women in rural areas tended to have fewer children. However, the study found no relationship between education and fertility in urban areas. According to one source, research in other Islamic 34 societies indicates that at least 6 years of primary education might be required to bring about significant declines in fer- tility. Female employment There is little direct evidence on the relationship bet- ween female employment and fertility in Pakistan. One study in Pakstan found some major differences in the desire for additional children between working and nonworking women. The main differences were between the women who had never worked and those who were employed by someone else; more of the latter said they did not desire additional children. Although the study showed that when other variables were controlled female employment did not significantly affect fer- tility desires, the study data suggests certain relationships that might have some policy implications. First, the number of sons is a crucial variable in fertility. Second, only a specific type of employment (employment utside the home) af- fects fertility desires. The lower fertility desires by women employed by someone else was not significant, but it migh e indicative of a transition in their motivation with possible implications for future employment policies. Finally, the actual use of contraceptives appears to be related to employment, particularly outside the home, in rural areas. Of the women interviewed in rural areas who desired no more children, 17 percent of those employed by someone else, but only 8 percent of those who never worked, reported using contraceptives at some time. Infant and child mortality Pakistan has one of the highest infant and child mortal- ity rates in the world. An analysis of research from several countries showed that uninterrupted declines in infant mortal- ity generally precede the decline in birth rates in these countries. A research study in Pakistan found that fertility is much higher among women who have experienced at least one infant death than among those who have experienced no infant deaths. A summary of the data obtained by this study is shown on the following page. 35 Comparison of Average Number of Children Ever Born with Number of Child DeatHs (sample of 2,7j1 women) (note a) Number of Number of Number of children children living who died ever born children 0 3.41 3.41 1 4.26 3.26 2 5.38 3.28 3 or more 6.46 3.46 a/Data was reported by the age of the women and the number of child deaths. Table summarizes age-adjusted data. The data tends to indicate that women who experience infant mortality compensate by having more births; those who do not experience infant mortality have fewer births. This suggests that the ultimate number of children desired is what governs. Although the data does not show that a reduction in infant mortality results in a lower growth rate, it does in- dicate that such reductions should lead to a voluntary de- crease in fertility and the more widespread acceptance of family planning services. EFFORTS TO IMPLEMENT DEVELOPMENT PROGRAMS BASED ON POPULATTON AND DEVELOPMENT INTERRELATIONSHIPS The GOP has recognized that there is a connection between economic development and fertility, and it has undertaken ef- forts to plan its programs so as to affect fertility. The concept is that social and economic change could moderate or eliminate the desire for additional children and thereby create new demand for family planning services. In 1975, USAID-sponsored consultants of the Interdis- ciplinary Communications Program (a private organization associated with the Smithsonian Institution) analyzed the probable demographic impact of Pakistan's preliminary staff papers for its fifth development plan (1975-80). The con- sultants analyzed a broad range of economic development ac- tivities, such as the rate of female employment outside the home. In general, the consultants said that direct measures to induce changes in both fertility and mortality would begin 36 to show results in the relatively short run (that is, 5 years). Other measures, such as affecting female education, fexal_ employment, infant mortality, and income level and is.ribu- tion, could not be expected to reduce general fertility rates until further into the future--perhaps 15 to 30 year;.- In discussing the consultant's work, a rSA') c fficJi] who participated in the analysis said Lbat i seuved as a challenge to demographers and planners in Pakistan to evolve a comprehensive, multidisciplinary approach o -opulation planning. He felt that, although the provision oif family planning services will reduce family sizes, it wili not be sufficient to bring about major declines in fertility. Ac- cording to him, developing countries that have experienced important fertility declines during the past two decades have generally had vigorous family planning programs and important improvements in the standard of living of many of their people. Pakistan's fifth development plan, still under prepara- tion, is not expected to be formally released until sometime this year. USAID officials told us that the draft plan in- corporates almost all of the recommendations on development and population interrelationships resulting from the 1975 demographic analysis. USAID officials also said that, as an indication of the seriousness with which population problems are viewed by the government, the plan is expected to include a separate section on population and population planning pro- grams. The GOP's Planning Secretary publicly stated in February 1976 that the government's fifth plan strategy for dealing with the population problem consists of two principal compo- nents. First, the government recognizes the connections be- tween economic development and fertility and, therefore, real- izes that growth and welfare objectives must be pursued nc+ only for their own sake but also because of their lo10: te- impact on population growth. The second element in - government's strategy is to vigorously pursuIe the famin± planning program, which can have an immediate ;:crt- rin impact on reducing the crude birth rate. The Secretary said that the most important feature of the strategy is that it seeks to push the economy to a high investment and growth path. He explained that the compelling reason for accelerated growth is the urgent need to resolve the population problem. He felt that unless per capita in- come rises very significantly, frtility is not affected. 37 The Secretary provided the following information on specific sectoral targets in the fifth plan: 1. Health--Total coverage is expected to increase from 20 to 50 percent of the population during the fifth plan period. Potable water supplies are to increase from 54 to 66 percent coverage of the population in urban areas and 11 to 25 percent in rural areas. Improved health care and more potable water are ex- pected to result in a reduced mortality rate, especially for infants and children. The improved outlook for the survival of children is expected to have an important bearing on family decisions con- cerning planned family size. 2. Education--The plan calls for an increase in educa- tional expenditures from 1.8 to 2.5 percent of the GNP. More emphasis will be placed on primary education. The plan sets a target of 100 percent coverage for boys (now 68 percent) and 80 percent for girls (now 29 percent). Special emphasis would be placed on expanding female education. It was expected that the ncreased school enrollment would lower the birthrate. The plan also provides for an adult literacy program aimed at educating 1 million persons, including 400,000 women. Special emphasis would be on educat- ing young adults, who are also the target of popula- tion planning. 3. Employment--The plan calls for creating 3.5 million jobs, thus taking care of labor force growth over the plan period. Keeping in mind population objec- tives, stress will be placed on labor-intensive em- ployment and the employment of women, especially in public sector, health, and education jobs. A USAID official told us that in August 1976, one of the consultants who participated in the 1975 demographic impact study would cochair a conference dealing with the 1975 study recommendations in more detail. The official indicated that the conference would consider the technical steps necessary to implement the study recommendations. Technical representa- tives of the various GOP ministries were to be present. From the standpoint of effectiveness, acceptability, and economy, family planning services can often most practically be provided as part of health, nutrition, or other development 38 programs. GOP and USAID officials favor such an approach to family planning in Pakistan. The Demographic Policy and Action Research Center (see p. 20) has begun activities to provide population materials in teacher training courses and new school curriculums. Family planning services have been available for several years Qs part of the national health network. USAID officials noted, however, that the movement toward integration is just beginning. They pointed out that the present coverage of social services, such as health serv- ices, is often so poor and limited as to preclude any effort to provide family planning services with them. The Family Planning Association of Pakistan is pilot testing a project to provide family planning services as part of the GOP's rural development program. According to USAID officials, the GOP plans to include family planning as part of its nationwide rural development program, which is expected to be operational throughout Pakistan by 1985. Also, plans for a basic health services project for Pakistan provides for including family planning services among the other project health services. Use of incentives/disincentives One function of the GOP's Demographic Policy and Action Research Center is to make innovative experiments, such as testing various incentive schemes for promoting family plan- ning. The Center is just getting started in this area and is planning to undertake a community incentive project. A USAID official pointed out that this type of experimentation is very difficult and has not been tried in Pakistan before. The official also told us that the Center is considering a sterilization incentive project, under which a person who submits to a sterilization will be given compensation in the form of a bond redeemable in several years. A Pakistani researcher suggested the development of incentives for smaller families and disincentives for larger families. He noted that in rural areas the most valued items are agricultural inputs (for example, tractors, threshers, irrigation wells, fertilizer, and seeds) and suggested that incentives might involve these items. The researcher also believed that the social pressures tc have more children should be removed by giving greater recognition to members of small families. He suggested special preference be given to these people in such areas as employment, passports, and training abroad. 39 Population impact statements In January 1976, USAID began requiring that all new projects in Pakistan include a population impact statement assessing the effect of the project on fertility and mortal- ity. The impact statement was expected to increase the probability that development projects would help achieve USAID's population objectives by modifying projects that were not sufficiently sensitive to demographic variables and by making USAID staff more aware of the importance of considering demographic variables when planning new projects. To illustrate the value of the population impact state- ment, a USAID official cited a recent demographic analysis of a farm water management project. The project would provide substantial employment opportunities in rural areas. Accord- ing to the official, an assessment of the project's demographic impact led to the recommendation that USAID make a special effort to provide job opportunities for women so that the project would have a greater impact on fertility. Population planning project USAID had provided about $525,000 in support of the population planning project through agreements begun in fiscal years 1973-75. An additional $79,000 was planned in a fiscal year 1976 agreement. The purpose of the project is to help the GOP develop a population section in the Pakistan Institute of Development Economics. The population section is to (1) assess what an economic- ally realistic population growth rate for Pakistan would be and (2) determine on a continuing basis the impact of various sector plans, programs, laws, regulations, and government policies on population growth rates. The section is to be able to -- study the impact of population growth rates on the national well-being, -- develop recommendations on both population growth and distribution, -- develop recommendations on both population-responsible and population-influencing policy through appropriate research and analyses, and -- foster increased understanding of opulation issues among government officials at all levels and among the public. 40 According to the director of the Institute, its primary objectives are to help the GOP formulate population policy and evaluate population programs. Planned population research and development project NID has approved $800,000 for use over a 3-year period beginning in fiscal year 1977 to: -- Support the Population Planning Council's Demographic Policy and Action Research Center activities in action and experimental research, test'ng of innovations in family planning services delivery, communications and motivational materials, and such beyond family plan- ning measures as incentives for the delay of births or sterilizations. -- Sponsor research on the determinants of fertility and population impact analysis. A USAID official said that funds for population impact analysis, which will amount to about $50,000 to $75,000 a year, will be channeled to the GOP's Planning Commission, which will in turn sponsor research studies. According to the official, this portion of the new grant will replace USAID's existing project grant with the Pakistan Institute of Development Economics. The official noted, however, that the Planning Commission will rely heavily on the Institute to carry out its research and that this direct relationship should result in the research being more relevant to the Commission's needs. 41 CHAPTER 7 CONCLUSIONS, AGENCY COMMENTS AND OUR EVALUATION, AND RECOMMENDATIONS CONCLUSIONS Pakistan's rapid rate of population growth is one of its most serious problems. Efforts to reduce ponulation growth have been underway since the early 1950. Major features of the current Expanded Population Plan- ning Program, started in 1973, that differ from past efforts include a system of continuous motivation and efforts to make contraceptives widely available at a price even the poorest can afford (contraceptive inundation). After 1973 an organization was established to devise national policy options to promote small families (referred to as beyond family planning measures). Efforts were made in 1975 to expand the availability of sterilization services. The ultimate goal of the expanded program was to reduce the crude birth rate from an estimated 45 per 1,000 to 35 per 1,000 by 1978. To achieve this goal, it was esti- mated that at least 16 percent of all eligible couples and 25 percent of Pakistan's young fertile couples would have to be motivated to use contraceptives. The program has not had the desired impact of increas- ing the number of couples using contraceptives. Available information indicates that the percentage of couples using contraceptives in i976 was about the same as it was in the late 1960s. In addition, those using contraceptives are primarily older couples with large families--not the younger couples targeted as necessary to attain the program goal. Few components of the program are working as planned. The GOP is way behind schedule in implementing management improvements in such areas as contraceptive supply and dis- tribution, manpower and training, project data feedback, publicity and communication, and automotive fleet operation and maintenance. The continuous motivation system has been ineffective. Problems include a shortage of trained workers, the teams' inability or unwillingness to make the prescribed number of visits to eligible couples, and the fact that workers are usually not residents of the villages they visit. 42 Available information indicates that contraceptive inundation has not been successful either in insuring that stipulated quantities are available at targeted outlets or in increasing demand. Although large quantities of contra- ceptives were delivered to Pakistan, they have not been dis- tributed to users on the scale planned. The number of out- lets involved in the effort is far below the number planned, and many cooperating outlets still do not have inundation stock levels on hand. However, contraceptives are more widely available in Pakistan than ever before. Nevertheless, demand is not increasing. Quantities of or.l contraceptives distributed each month have remained below early 1976 levels, and quanti- ties of condoms distributed during 1976 have remained essen- tially constant. In addition, indications that primary contraceptive users are older Pakistanis who already have large families suggests that the widespread availability of contraceptives (1) has had only a limited impact on the birth rate and (2) has not resulted in increased demand but rather in fulfilling the needs of those who have already achieved their desired family size. There appear to be two prominent reasons underlying the relative ineffectiveness of the program: -- The social, economic, and cultural norms of a largely subsistence-level target group that conflict with national birth rate reduction objectives. --A questionable GOP commitment to the program. The 1976 AID-contracted program evaluation also cited these as reasons for the program's ineffectiveness. We believe the unimpressive results of the expanded pro- gram, particularly the inundation effort, are attributable in part to AID's encouraging and entering into the program (1) without adequate assurances of the government's willing- ness and capability to carry out the program and (2) with little attention to the incentives necessary to cause couples to desire smaller families and use family planning services. We further believe that the level of AID's involvement with the program siLice 1973 despite the obvious existence of cri- tical impediments to program success was based principally on the views of its Office of Population in Washfngton that the supply of family planning services would meet an assumed latent demand and result in actual use of such services. 43 As the largest donor, AID has encouraged the GOP to make needed family planning program management improvements. The GOP, however, has neither made the improvements nor estab- lished an information system adequate to enable AID to monitor and measure program progress and to provide reasonable assur- ance that program objectives are being met. We believe AID should require such a system of any country in conjunction with its continuation of support of population reduction efforts. We also believe AID should require a country's govern- ment and institutions to demonstrate a willingness and capa- bility to engage in such a program. Such an approach would enable AID to make program adjustments on a more timely basis and would provide for the more efficient use of scarce finan- cial resources. We also believe that AID should encourage the full co- ordination of donor population assistance. Three organiza- tions directly or indirectly supported by AID do not partici- pate in any of the donor assistance meetings. Additional approaches to reducing population growth should be explored and adopted where feasible. To increase and sustain the appeal of family planning, social and eco- nomic changes that would make smaller families more attractive should be considered in planning population and development assistance projects. A limiting factor, however, to devising policies and programs for reducing population growth is the absence of sufficient empirical information on the factors affecting fertility behavior. AID and the GOP are making some tfforts to obtain data and develop new approaches, as discussed in chapter 6. We believe that AID should continue to stress such efforts. AGENCY COMMENTS AND OUR EVALUATION The Departm,,ent of State and AID provided written com- ments on this report. (See apps. IV and V.) Also, comments were furnished by State and AID officials in discussions of later revisions to the report. The written and oral comments generally agreed with the findings, conclusions, and recommen- dations. The Department of State particularly concurred in two report positions: (1) that the experience in Pakistan illus- trates the need for seeking solutions to population growth problems within the broader context of social and economic 44 change and (2) that future U.S. population assistance should take into account the connection between economic development and fertility. State also emphasized the importance of women's rights and village organizations in successfully formulating a population program. AID officials a,reed with these views and also stressed the need for providing family planning services. AID fund the report to be comprehensive and accurate, agreed that population gowth rates have not been signifi- cantly reduced in Pakistan, and said the report confirmed AID's assessment that the GOP must improve its family planning program management before it can achieve a significant reduc- tion in fertility rates. AID also agreed that it should (1) continue to foster research on the links between fertility, family planning acceptance, and many facets of social and economic develop- ment and (2) continue to include population corsiderations in other development programs. AID pointed out, however, that since the precise nature of the relationship between fertility and social and economic variables is largely un- known, developing other approaches to population growth will take time. AID said it will continue to support innovative action research studies on alternative approaches to fertility regulation. Concerning contraceptive inundation in Pakistan, AID argued that, with family planning services frequently un- available to users because of program difficulties, there is not sufficient grounds to comment on the effect availability of contraceptives has n fertility. Although we recognize and our report addresses program administration, operational, nd other problems, we believe that this program's lack of success under conditions where contraceptives were more widely available than ever before indicates that merely making contraceptives available is not sufficient to influence couples to adopt family planning. Contraceptive availability is just one element to be con- sidered in devising an effective program to curb population growth. When AID provided its comments on the report, the na- ture and extent of future support for the program was still under consideration. AID concluded by stating that it is reviewing the Pakistan program to (1) identify the issues, (2) resolve policy questions, and (3) develop a strategy to guide future U.S. actions. 45 RECOMMENDATIONS We believe the lessons learned from the Pakistan experience should be useful in considering assistance to any developing country. In our opinion, the AID-contracted program evaluation report realistically assesses the issues that will have to be addressed before the Pakistan popula- tion program's effectiveness can be improved. The evalua- tion may also be of value in formulating population assist- ance programs to other countries. We recommend that the AID Administrator: 1. Reassess the advisability of continuing assistance to developing countries (a) which do not have a management system and an information system in existence (or actively under development) sufficient to reasonably assure that program objectives are being met or (b) whose government and institutions have not demonstrated a willingness and capability to carry out the program. 2. Support and stress the need for identifying, develop- ing, and implementing well-planned additional and innovative approaches to population problems in all developing countries through such measures as the A19-sponsored research planned on the determinants of fertility in Pakistan. 3. Disseminate the contractor's evaluation of the Pakis- tan program for the information and use of all offi- cials responsible for implementation of AID-financed contraceptive and family planning programs in Pakis- tan and in other countries. 4. Use the results of the contractor's evaluation as a guide in formulating any assistance program in- tended to have an impact on fertility. 5. Encourage greater coordination among donors of popu- lation assistance, particularly with respect to the attendance and participation of voluntary organiza- tions at donor assistance meetings. Concerning recommendation 1 as it relates to Pakistan, in an earlier report to the Congress 1/ we expressed concern 1/See note, p. 24. 46 about (1) the absence of an inundation feasibility study and (2) the problems of supply and distribution, personnel train- ing, and management information feedback. We recommended that the Secretary of State and the Administrator of AID seek additional upport for the population planning program from the GOP in conjunction with the provision of any additional U.S. funds. Concerning recommendation 2, we believe that Pakistan's recognition of the connection between economic and social development and fertility and AID's plans to provide funds to Pakistan for research on the determinants of fertility are consistent with a position taken by AID in a July 1976 pclicy statement o ruture directions of U.S. population- related assistance. The document sets forth a broader ap- proach for AID to help reduce population growth through development programs that seek to change social and economic condition<. AID has cautioned, however, that since the pre- cise nature of the relationship between fertility and social and economic variables is largely unknown, developing other approaches to population growth will take time. Concerning recommendations 3 and 4, AID plans to share the contract evaluation findings with other bureaus and to use them in formulating the nature and shape of future U.S. assistance to Pakistan's population program. We believe, however, that the evaluation and Pakistan's experience with contraceptive inundation would be of interest to AID missions abroad and of value in formulating population programs for other countries. 47 CHAPTER 8 SCOPE OF REVIEW Our work was directed primarily toward obtaining comprehensive data to describe Pakistan's problems and to describe ad edluate, as population growth much as possible, past, present, and planned assistance for reducing the popu- lation growth rate as part of efforts to of life. improve the quality We reviewed program documents, reports, correspondence, and other data available at the Washington offices of the Department of State and AID. and Pakistan discussions with officials of State, AID, We also held international and private voluntary organizations, and the Pakistan. Government of 48 APPENDIX I APPENDIX I OTHER DONOR ASSISTANCE Six donor countries (besides the United States), six private international organizations, and one intergovernmental organization have provided family planning and population as- sistance to Pakistan. Assistance from these donors amounted to over $27 million between fiscal years 1960 and 1976. Two cuntries, Sweden and the Netherlands, no longer pro- vide population assistance. Sweden contributed about $10 mil- lion from fiscal years 1960 to 1972, and the Netherlands con- tributed $305,000 in fiscal year 1970. Doiors _Excluding the United States) Currenty Prving PoPulaton Assistance Year Approximate support cumulative Donor began assistance Norwegian Agency for Inter- national Development 1975 $ 367,000 Australia 1975 63,000 United Kingdom 1967 771,000 Federal Republic of Germany 1974 1,200,000 Asia Foundation 1975 20,000 Ford Foundation 1955 4,685,000 Association for Voluntary Sterilization 1974 315,000 Family Planning International Assistance 1975 54,000 Family Planning Association of Pakistan 1953 a/2,355,000 United Nations Fund for Population Activities 1971 6,400,000 International Association of Schools of Social Work 1974 (b) a/Includes only International Planned Parenthood Federation grants. b/Not available. DONOR COUNTRIES The four donor countries (except the United States) cur- rently providing population assistance to Pakistan are Norway, Australia, the United Kingdom, and the Federal Republic of Germany. 49 APPENDIX I APPENDIX I Norwejian Aqency for International Develoment The Norwegian Agency for International Development is providing a $4.3 million grant to Pakistan to help finance the costs (rent, salaries, electricity, etc.) of existing and planned family welfare clinics. The grant will be pro- vided during fiscal years 1976-79. The family welfare clinics provide such services as family planning (including IUD insertions), prenatal and post- natal care, mother and child health, curative health, and services to prevent illness. Pakistan plans to expand the number of clinics from 550 to 1,300 during fiscal years 1976- 78, thereby making family planning services more accessible. Australia During fiscal year 1976, Australia provided 3,000 gross of condoms valued at $13,000 and photographic equipment for the Population Program's Training, Research, and Evaluation Canter valued at $50,000. The Government of Australia repre- sentative at an annual donor meeting indicated that his coun- try would continue to make a small contribution to the program. United Kingdom The United Kingdom shared in providing the supplies re- quired by the inundation program by furnishing 1 million cycles of pills and 55,000 gross of condoms during fiscal years 1975 and 1976, respectively. It has also agreed to provide 60 reconditioned land rovers during fiscal year 1976. Assist- ance during these 2 fiscal years is estimated at about $700,000. The United Kingdom has agreed to provide, during fiscal year 1977, an additional 60 land rovers, 100,000 gross of condoms, and a consultant in demography. Federal Republic of Germany During fiscal year 1975, the Federal Republic of Germany provided 400,000 gross of condoms, valued at $1.2 million. It was considering providing another 250,000 to 300,000 gross of condoms. The GOP was negotiating a low-interest, 50-year repay- ment loan with Germany for the construction of a condom fac- tory estimated to cost about $4.4 million. The loan was ex- pected to be finalized by October 1976, and production was expected to begin about September 1978. n May 1977, however, an AID official said that Germany is reconsidering the feasi- bility of the factory. 50 APPENDIX I APPENDIX I PRIVATE INTERNATIONAL ORGANIZATIONS Six private international organizations are providing family planning and population assistance to Pakistan: the Asia Foundation, the Ford Foundation, the Association for Voluntary Sterilization, the Family Planning international Assistance, the International Association of Schools of Social Work, and the International Planned Parenthood Federation through the Family Planning Association of Pakistan. Asia Foundation The Asia Foundation is a nonprofit organization incorpo- rated in California. One of its basic purposes is to sup- port Asian individuals and institutions, public and private, in sear.ching for and applyirg innovative solutions to the problems of social and economic growth. During the early years of Pakistan's family planning program, the Foundation reportedly provided assistance to the Family Planning Association of Pakistan. One early assistance project involved support of a cartoonist to study animation techniques, and an animated film is expected to be released soon. During fiscal sear 1976, the Foundation provided two grants totaling about $20,000 to Pakistan's Population Plan- ning Council. Ltne grant supported a seminar for 62 teacher trainers on the new population education curriculums to be introduced in Pakistani schools in 1977. The second grant supported the Council's effort to involve teachers in the national population planning program. Ford Foundation The Ford Foundation is a private, nonprofit institu- tion serving the public welfare. The Foundation has been supporting Pakistan's population efforts since the 1950s. In the earlier years, the Foundation provided grants to the Population Council, Johns Hopkins University, and the Uni- versity of California o assist in Pakistan's family plan- ning efforts. This assistance helped support consultant services, training, and research and demonstration projects in family planning. In recent years the Foundation has provided: -- A $228,000 grant to help the GOP (1) train census personnel, (2) expand and improve the statistical base for population measurement and analysis, (3) 51 APPENDIX I APPENDIX I plan for a population reference service, and (4) contribute to the body of information required for considering and advancing popu- lation policies. --A $420,800 grant to help the Pakistan Institute of Development Economics to broaden its research in social and population-related issues. --A $25,000 grant to the GOP's Demographic Policy Action Research Center to support its research on community incentive schemes. Association for Voluntary Sterilization The Association for Voluntary Sterilization prom)tes male and female sterilizations, on a national and worldwide basis. Cumulative AID support provided to the Association through fiscal year 1975 amounted to about $5 million. The Association has funded or expects to fund sterilization pro- jects in Pakistan costing approximately $315,000 from 1974 to 1976. ThE projects are being or will be carried out in two hospitals and the Family Planning Association of Pakistan to provide (1) training for physicians in sterilization tech- niques, (2) medical equipment, (3) funds for medical personnel salaries, and (4) reimbursement for sterilization costs. Family Planning International Assistance The Family Planning International Assistance is the international arm of the Planned Parenthood Federation of America, an affiliate of the International Planned Parenthood Federation. Cumulative AID support to the organization through fiscal year 1975 amounted to about $16 million. The organization is funding two projects in Pakistan: the Pakistan Medico International Family Planning Program in Karachi and the Urban Slum Family Program in Rawalpindi. The Pakistan Medico International Family Planning Program is a 3-year project being conducted in three areas of Karachi. In each case field worker couples inform people about family planning and the availability of contraceptive services, dis- tribute contraceptives, and refer people desiring IUDs or sterilization to clinics. About $41,000 was budgeted for the first 14 months of the project (May 1975 to July 1976). The Urban Slum Family Planning Program involves a 1-year, $12,959 grant to the Social Welfare Society of Rawalpindi. The project goals are to make family planning information and services accessible to the people of a densely populated slum 52 APPENDIX I APPENDIX I area in Rawalpindi and to establish a system through which family planning services can be made continuously available to the people by trained resident family planning agents. Under the project, lady home visitors work out of the social welfare center to educate people about family planning, dis- tribute contraceptives, and refer women to the center for IUDs and sterilizations. International Assocication of Schools-of-Social Work The International Association of Schools of Social Work, an incorporated, nonprofit educational association, entered into a 5-year contract with AID on July 1, 1971, to stimulate the training of qualified social work personnel for population and family planning responsibilities in less developed coun- tries. This is to be achieved by -- expanding the functions of social work to include family planning responsibilities, -- initiating curriculum changes to incorporate population and family planning content in social work education, -- providing opportunities for faculty members to acquire knowledge of population and family planning, and -- preparing students to make effective use of population and family planning knowledge in all areas of social work practice as well as in specialized programs. Two pilot projects were begun in Pakistan during January 1974: one at the University of Karachi and one at the Univer- sity of Punjab in Lahore. According to an Association report, the two schools had (1) reviewed and reorganized their curric- ulums to include population and family planning as appropriate to the needs of the project and (2) trained faculty members to teach population and family planning in all areas of the cur- riculum. Family Planning-Association-of-Pakistan The Family Planning Association of Pakistai i an affili- ate of the International Planned Parenthood Federation. Cumu- lative AID support provided to the Federation through fiscal year 1975 amounted to about $68 million. The Association spearheaded the family planning efforts in Pakistan when it began operating in the country in 1953. The Association 53 APPENDIX I APPENDIX I obtains most of its funds from the Federation's London head- quarters. Between 1962 and 1975, grants totaling over $2.3 million were received from this source. The GOP also makes a small grant to the Association ranging from $10,000 to $40,000 annually. Before 1973, USAID was also providing grants to the As- sociation. These grant were discontinued, however, because the mission was spending too much time monitoring the Asso- ciation's many small projects. Examples of current projects The following are examples of the major projects being undertaken: 1. Test marketing project--with the assistance of marketing consultants and an advertising firm, the Association plans to launch a condom and pill test marketing project in five market towns. They have chosen brand names and will package the contracep- tives. The test is expected to last about a year and should provide data to support various marketing techniques. It is hoped that some techniques that are successfully tested will be adopted in the GOP's national program to help spur sales in the program's 30,000 commercial outlets. 2. Industrial coverage project--In this project labor union eaders and mide-lvel representatives of the labor force are given educational courses in family planning. From these courses volunteers are recruited to organize worker education courses in their factories and to manage, organize, supervise, and promote family planning motivation and ervice activities. During 1974 over 48,000 people were contacted through this project. 3. Youth Organization for Progress and-Prosperity-- This organization was formed in September 1973 to initiate youth-oriented family planning programs. Special emphasis is given to population education by holding lectures and discussions and providing reading materials. 4. Sterilization--Model clinics were established in Lahore and Karachi to provide sterilization services to men and women. During 1974 about 270 sterili- zations were performed in these clinics. Five more clinics are planned. 54 APPENDIX I APPENDIX I 5. Integrated-Rural-Development-Program--The Association is contributing a family planning component to the GOP's national Integrated Rural Development Program in an attempt to make family planning available to rural people in projects for improving agricultural development, health, education, cooperatives, etc. The program involves explaining the benefits of family planning to cooperative organizations, youth groups, and community leaders. Volunteers are recruited to do motivational work, to refer clients to government clinics, to identify sales points, and to supervise the distribution of contraceptives. The Family Planning Association of Pakistan's efforts to integrate family planning with the government's Integrated Rural Development Program may offer alternative approaches to the current government population program. Under the govern- ment's program, male and female motivators are used to promote and distribute family planning services. However, these moti- vators are generally not residents of the villages they visit. The Associ3tion, in integrating family planning with the devel- opment project, relies on local villagers to promote family planning. It recruits volunteers from the village, trains and educates them in family planning, and then uses them to pro- mote family planning in the village. Association officials believe that using local residents instead of outside motivators to promote family planning is a better approach. A village leader at one Association project said that government workers cannot effectively communicate with the local people on such a sensitive subject as family planning. He pointed out that, under the Association's pro- ject, villagers are more willing to discuss the subject with the local people. The Association maintains a record of the number of family planning acceptors for its projects. It uses this sta- tistic along with the cost of the project to measure program effectiveness and efficiency (that is, deriving the project cost per acceptor, which is compared with other projects). The Association, however, does not compile such data as the percentage of fertile couples accepting family planning serv- ices or the age and number of children of the acceptc . This data would be needed to more effectively evaluate th i socia tion's projects and to provide a comparison with the P pro- gram. Association officials said they often do not have the funds or staff tc collect the data needed to measure pro- gram effectiveness and impact. They also did not want to 55 APPLNDIX I APPENDIX I keep as detailed records as the government because it would be too time consuming and difficult. They acknowledged, however, that determining the effectiveness and impact of their projects would be useful. INTERGOVERNMENTAL ORGANIZATIONS--UNITED NATIONS FUND FOR POPULATION ACTIVIT-E The United Nations Fund for opulation Activities takes a leading role in promoting and coordinating population pro- grams in the U.N. system. The Fund's assistance to Pakistan amounted to about $6.4 million fob fiscal years 1971-76. Assistance to the GOP is provided under an agreement which covers a 5-year period (July 1974 through June 1979), whereby the Fund pledged $15 million to support the GOP in fulfilling its broad aims concerning population activities. During the first year of the agreement, the Fund contibuted $3 million to support: -- Salaries of field workers, lady motivators, and lady welfare visitors. -- Publicity. -- Local currency support for the Training, Research, and Evaluation Center located in Lahore; the post partum program; and regional training institutes. -- Local currency support for medicines, for clinics, and for seminars, workshops, and other group training. -- Contraceptives. 56 APPENDIX II APPENDIX II TOTAL FUNDING OF POPULATION ASSISTANCE EFFORTS IN PAKISTAN--ALL SOURCES FISCAL YEARS 1960-76 Approximate cumulative Funding source assistance Government of Pakistan $ 78,337,917 AID c/58,815,809 Other donoL: Donor countries $12,576,000 Private international organizations a/7,429,639 United Nations Fund for Population Activities a/7,547,000 International Associa- tion of Schools of Social Work (b) 27,552,639 Total $164,706,365 a/The United States is major contributor to the Fund and to most of these private international organizations. b/Not available. c/About $21.5 million of this amount consisted of dollar equivalent U.S.-owned local currency provided largely between 1966 and 1970. 57 APPENDIX III APPENDIX III EUREAU OF THE CENSUS PROJECTIONS: IMPACT OF POPULATION GROWTH The following data on Pakistan was supplied by the Socio- Economic Analysis Staff, International Statistical Programs Center, Bureau of the Census. The Long-Range Planning Model (LRPM-2) developed by that office was used to make these pro- jections. The medium Census staff projections are derived, in part, from U.N. medium-population growth estimates. Pro2ected_Poeulation (millions) 1975 69 1980 80 1J85 92 1990 106 1995 122 2000 140 Prolected Life Expectanc y at Birth Point estimates Male Female 1980 53.6 53.3 1985 55.4 55.1 1990 58.5 58.2 1995 61.0 60.7 2000 63.0 62.7 Enrollment Primary Middle Secondary College University (thousands) Males 1975 3,800 890 480 180 80 2000 9,800 1,600 1,600 680 360 Females 1975 1,490 220 100 60 13 2000 8,300 1,610 620 290 75 58 APPENDIX III APPENDIX III Total Education OEerationi Costs (millions/1975 Period U.S. dollars) 1976-1980 $1,250 1995-2000 4,524 Health Facility and Manpower Needs 1970 2000 (thousands) Hospitals 0.5 4.1 Health units 3.4 26.7 Beds 36.0 262.1 Physicians 19.0 58.0 Dentists .5 4.4 Nurses 9.1 37.8 Midwife-Nurses 4.4 65.7 Midwives 1.1 26.5 Lady health visitors 2.6 46.4 Proected Work Age Population (15-64) (millions) 1975 37 1980 43 1985 50 1990 58 1995 67 2000 78 Ratio to Population Labor force Ratio (millions) 1975 26.1 0.38 1980 29.4 .37 1985 33.1 .36 1990 37.7 .35 1995 42.9 .35 2000 49.0 .35 59 APPENDIX III APPENDIX III Ratio of Selected_Age Grou os to Total Population 0-14 15-64 65 and over 1975 0.44 0.54 0.030 1980 .43 .54 .031 1985 .43 .54 .032 1990 .42 .55 .033 1995 .42 .55 .034 2000 .41 .56 .036 Based on the U.N. medium population estimates and analy- sis, the Bureau of the Census' International Statistical Pro- grams Center projects that, from 1975 to 2000, the number of PaKistanis living in rural areas will rise from 50 million to Al million while the number of Pakistanis in urban areas will advance from 19 million to 79 million. 60 APPENDIX IV APPENDIX IV DEPARTMENT OF STATE AGENCY FOR INTERNATIONAL DEVELOPMENT WAIHINTON, D.C. MS Audtwr QGemnl March 16, 1977 Mr. J. K. Fasick Director International Division U.S. General Accounting Office 441 G Street, N.W. Washington, D.C. 20548 Dear Mr. Fasick: Thank you for providing te draft report "Population Assistance to an Asian Country" for AID comments. The draft has been reviewed by officials familiar with the program reviewed. They are in agreement with most of the major observations and the recommendations. The attached brief comments provide the Agency's reaction to the report. A listing of more detailed comnents was provided directly to your review staff. If I can be of any further assistance in this matter, please call on me. Sincerely yours, Harry Cromer Attachment: a/s 61 APPENDIX IV APPENDIX IV AID COMMENTS ON GAO REPORT: POPULATION ASSISTANCE TO AN ASIAN COUNTRY We find the GAO report to be comprehensive and accurate. Its recommenda- tions are reasonable and, we believe, implementable. The Agency intends to share the findings of the Family Health Care, Inc. report, the evalua- tion alluded to in the GAO report, with other Bureaus. We agree that the findings of that evaluation report should play a role in formulating the nature and shape of future U.S. assistance to Pakistan's population pro- gram. Cur views on other specific points in the GAO report fellow: Program Results. We agree that population growth rates have not been significantly reduced by the family planning program. As the report notes, our concern has led us to make a number of recent surveys and attempts to improve the situation. The FY 1972 Congressional Presentation stptes that the program objectives are not being met. Management and Operations. The draft rport confirms our assessment that the Government of Pakistan must improve its family planning program man- agement as a prerequisite to achieving a significant reduction in fertility rates. Alternative Approaches to Fertility Reduction. We agree with the report's conclusion (p. 51) that AID should continue to foster research on linkages between fertility, family planning acceptance, and many facets of social and economic development, and should also continue to include population considerations in other development programs. Since the precise nature of the relationship between fertility (and contraceptive use) and social and economic variables (e.g. health, education, employment) is still largely unknown, we would caution thac development of other approaches to popula- tion growth will take time. Although AID programs are directed to improvement of level and distribution of income, educational level of women, employment of women, and infant and child mortality rates--independent of their effect on fertility--the Agency is now giving specific consideration to their impact on fertility. AID will continue to support innovative action research studies on alternative ap- proaches to fertility regulation. Inundation: The report points out (e.g. pp. 31-33) that numerous admini- strative and operational difficulties prevented the program's "contracep- tive inundation" effort and Continuous Motivation System from providing couples with ready access to contraceptive information and supplies. Therefore, with family planning services frequently unavailable, there are insufficient rounds for claiming that the experience so far in Pakistan disproves or ven tests the hypothesis that "a major inhibition to success of earlier family planning efforts was the lack of access by most couples to the information and means necessary to limit their fertility." We suggest that further research could improve assessments of existing demand 62 APPENDIX IV APPENDIX IV for family planning among both rural and urban populations, and to find out the extent to which other social, cultural, and economic factors pre- vent acceptance of family planning, even when it is available. Executive Review. AID is now carrying out a review of the Pakistan pro- gram designed to: (a) identify the issues; (b) resolve policy questions; and (c) make plans for future actions. This review which should be com- pleted by March 15, is being made within the context of impending Congres- sional hearings, the planned meeting of international population donors in April 1977, and preparation of the FY 1977 Project Agreement between the U.S. and Pakistan. PHA/PROG 3/3/77 GAO note: Page references in this appendix may not corres- pond to page numbers in the final report. 63 APPENDIX V APPENDIX V -i DEPARTMENT OF STATE Washington. D.C. 20520 March 28, 1977 Mr. J. K. Fasick Director International Division U.S. General Accounting Office Washington, D. C. 20548 Dear Mr. Fasick: I am replying to your letter of January 4, 1977, which forwarded copies of the draft report: "Population Assistance to an Asian Country." The enclosed comments were prepared by the Director of the 3ffice of Population Affair<. We appreciate having had the opportunity to review and comment on the draft report. If I may be of further assistance, I trust you will let me know. Sincerely, e .Williamson, Jr. Deputy Assistant Secretary for Budget and Finance Enclosure: As stated 64 APPENDIX V APPENDIX V GAO DRAFT REPORT: POPULATION ASSISTANCE TO PAKISTAN The Office f the Coordinator of Population Affairs and the Office o Population Affairs have reviewed GAO's draft report on Pakistan's family planning program and United States assistance to the program. We find it to be a useful summary of Pakistan's population control program and strongly concur in two of its principal recommendations: - That the experience in Pakistan illustrates the need for seeking solutions to population growth problems within the broader context of the need for social and economic change. - That future direction of U.S. population assistance should take into account the linkage between economic development and fertility. In general, we believe the report does not give sufficient emphasis to the importance of women's rights and village organizations in the successful formulation of a population program. All too often our family planning programs are presented to host governments and Congress as though these programs alone will solve the problems of overpopulation. There is no effort to go beyond family planning to include programs of social action and concern for the general well-being of the people. Especially in Pakistan we believe the problem must be attacked on a broader front than the mere supply of contraceptives. A comprehensive plan is required that would effectively influence the decisions that parents make about the number of children they have. Their decisions are based on far more than the availability of family planning supplies. They are related to socio- economic conditions that affect the family as a unit, its existence and potential. Clif d R. Nelson Direc or, Office of Population Affairs 65 APPENDIX VI APPENDIX VI PRINCIPAL OFFICIALS RESPONSIBLE FOR ADMINISTERING ACTIVITIES DISCUSSED IN THIS REPORT AEpointed ADMINISTRATOR, AGENCY FOR INTERNATIONAL DEVELOPMENT: John J. Gilligan Mar. 1977 Daniel Parker Oct. 1973 John A. Hannah Mar. 1969 ASSISTANT ADMINISTRATOR, BUREAU FOR POPULATION AND HUMANITARIAN aSSISTANCE: Allan R. Furman (acting) Mar. 1977 Fred O. Pinkham Apr. 1976 Allan R. Furman (acting) Mar. 1976 Henry S. Hendler (acting) Feb. 1976 Harriet Crowley (acting) Feb. 1975 Jerald A. Kieffer July 1972 DIRECTOR, OFFICE OF POPULATION, BUREAU FOR POPULATION AND HUMANITARIAN ASSISTANCE: R. T. Ravenholt July 1972 DIRECTOR, U.S. AID MISSION TO PAKISTAN: William A. Wolfler (acting) Apr. 1977 Joseph C. Wheeler Aug. 1969 66
Impact of Population Assistance to an Asian Country
Published by the Government Accountability Office on 1977-07-12.
Below is a raw (and likely hideous) rendition of the original report. (PDF)