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)

                          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)


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
                           WASHINGTON, D.C   0548


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
                                        Department of State
                                        Agency for International

             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-

             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

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

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

            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.)


DIGEST                                                 i

            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
            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
            1953-70                                   13
              GOP family planning program results     14
              Constraints on success of past pro-
                grams                                 16
              Expanded Population Planning Program    17
              Coordination of population assistance   21
              Constraints on program success          23
              Continued USAID efforts to improve
                program effectiveness                 20
              Findings, issues, and recommendations
                of program evaluation ccOt-ractor     29
            MODERATING POPULATION GROWTH              33
              Determinants of fertility               34
 CHAPTER                                                Page
                Efforts to implement development
                  programs based on population and
                  development interrelationships         36
             EVALUATION, AND RECOMMENDATIONS            42
               Conclusions                              42
               Agency comments and our evaluation       44
               Recommendations                          46
    8      SCOPE OF REVIEW                              48

   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
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



     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
     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.

     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.


     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.

     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.

     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

     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

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-

     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.

                                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.)

     The following table shows Pakistan's population by
area for selected census years and the rate of growth for
each year.

            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
  Prcvince           1.09       1.35        2.41        2.14     4.83
      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.

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.

                            CHAPTER 2

                       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:

       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
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.

Year        Slow growth       Medium growth         Rapid growth
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
capita income remained virtually stagnant and half of the
economic growth was consumed by the population increase.

     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 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.

     '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.

     Meeting Pakistan's educational goals is a tremendous
challenge because

     --80 percent (about 56 million) of the people are il-
     --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.

      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-

     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

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.

                           CHAPTER 3

      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.

     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.


     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

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.

     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 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

     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.

                          CHAPTER 4


     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.
     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
     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

        GOP Support of the P      lation Control Effort

                   GOP budget          Percentage of
                   support for           GOP budget
         Fiscal    population           allocated to
          year       program         population program
          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

       Cost component            FY 1973-75          (note a)
      (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
b/Dollars provided in the first project agreement to offset
  local currency costs.

     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

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,

     -- 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.


     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.)

                          CHAPTER 5


     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

    -- 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.)


     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.

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

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

     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.

     -- 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.

     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.

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

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-

     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.


      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.

     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.


     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.

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.

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

     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

     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

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.

                               CHAPTER 6



     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
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
panded program, which adopted a wider development-oriented
approach.  A Demographic Policy and Action Research Center
was established to explore national policy options
would encourage smaller families.  Research is planned on
ways to increase the demand for family planning
     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,
scientifically designed and conducted sample surveys
                                                      of human
fertility behavior.  The Pakistan Fertility Survey should be
useful to policymakers in Pakistan in considering
approaches to reducing or moderating population
                                                growth because
it was designed to meet their specific information
The survey is also intended to

     -- furnish accurate data on patterns of fertility
        infant/child mortality;

     --make analyses of fertility possible in relation
       female education, female employment, and infant/child

     -- furnish reliable information about the evaluation
        the effect of the family planning program; and

     -- help measure changes   in fertility since 1968.

     Survey fieldwork included interviewing about
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

October 1976.    (Some highlights of the report are described
on pp. 23, 25,   and 28.)


     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.


     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

     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

societies indicates that at least 6 years of primary education
might be required to bring about significant declines in fer-
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

     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.

         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.


     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

     In general, the consultants said that direct measures to
induce changes in both fertility and mortality would begin

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-

     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 faminĀ±
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.

     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

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.

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.

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.

                               CHAPTER 7




     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.

     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.

     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

     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.


     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-

     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

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
     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
     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.


     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.

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.

                          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,
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

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
b/Not available.


     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

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.

     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.

APPENDIX I                                         APPENDIX I


     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
     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)

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

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,

     -- 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-

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

                                                    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
$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

     1.   Test marketing project--with the assistance of
          marketing consultants and an advertising firm,
          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
          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.

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-

     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

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.

     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
     -- 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.

APPENDIX II                                        APPENDIX II



                      FISCAL YEARS 1960-76

     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.

APPENDIX   III                                                    APPENDIX III


                     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.



                             1975               69
                             1980               80
                             1J85               92
                             1990              106
                             1995              122
                             2000              140

                 Prolected    Life Expectanc      y   at Birth

       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


                 Primary     Middle      Secondary       College     University



1975              3,800        890              480         180          80
2000              9,800      1,600            1,600         680         360


1975              1,490        220              100          60          13
2000              8,300      1,610              620         290          75

APPENDIX III                                                   APPENDIX III

               Total Education OEerationi Costs

               Period                              U.S. dollars)

          1976-1980                                   $1,250
          1995-2000                                    4,524

           Health Facility and Manpower Needs

                                          1970            2000

         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)

                          1975                   37
                          1980                   43
                          1985                   50
                          1990                   58
                          1995                   67
                          2000                   78
                        Ratio to Population

                                 Labor force             Ratio


          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

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.

APPENDIX IV                                                         APPENDIX IV

                               DEPARTMENT OF STATE
                                 WAIHINTON, D.C. MS

  Audtwr QGemnl

                                                     March 16, 1977

 Mr. J. K. Fasick
 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

APPENDIX IV                                                     APPENDIX IV


 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-

 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

 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

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.


GAO note:     Page references in this appendix may not corres-
              pond to page numbers in the final report.

APPENDIX V                                                                 APPENDIX V

    -i                DEPARTMENT OF STATE
                           Washington. D.C.   20520

                                          March 28, 1977

  Mr. J. K. Fasick
  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.


                                              e       .Williamson,   Jr.
                                   Deputy Assistant Secretary
                                   for Budget and Finance

  Enclosure:   As stated

APPENDIX V                                             APPENDIX V


        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

        - 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

APPENDIX VI                                     APPENDIX VI



                   DISCUSSED IN THIS REPORT

    John J. Gilligan                           Mar.   1977
    Daniel Parker                              Oct.   1973
    John A. Hannah                             Mar.   1969

    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

    R. T. Ravenholt                            July   1972

    William A. Wolfler (acting)                Apr.   1977
    Joseph C. Wheeler                          Aug.   1969