2. Population policy in Pakistan 31
officially condoned family planning upon the urgings
of well-placed society women.
Elite women in South Asia have played a powerful
role in demanding female education, freedom from
restrictions of purdah, and legal rights. This tradition
of activism was continued after the creation of
Pakistan with the founding of the All-Pakistan
Women's Association, the first women's organization
in the country. Begum Saeeda Waheed, active in
APWA and the wife of a prominent businessman in
Lahore, became an advocate of birth control when
her maid died attempting to abort a fourth pregnancy.
The original logic for beginning the work was simply
the shock of discovering that a woman should have
to risk taking her life to control her own fertility.1
Waheed consequently founded the Family Planning
Association of Pakistan in Lahore in 1952.2
A close
network of family planning activists soon formed,
linking Lahore with Dhaka in East Pakistan and with
a group of activists and young demographers in
Karachi.
The government's reaction to FPAP was mixed.
Waheed was promised a token amount approved by
a special Parliamentary vote in 1958, to be channelled
to FPAP through the Ministry of Health. FPAP
realized that the allocation may just have been made
to be rid of the nuisance created by the vocal group
of well-placed Begums, or upper-class ladies, which
they were; but for them a point had been made.
The major breakthrough which brought family plan-
ning into mainstream development policy took place
when the agenda of FPAP coincided with the interest
of Ayub Khan, President and military ruler of
Pakistan from 1965 to 1969. His imagination was
captured by the problem of overpopulation, and the
effect this would have on national development. This
is a subtle but important difference from the FPAP
concern with the ill-health of women caused by
pregnancy; yet the two approaches coincided suc-
cessfully in that they both prescribed family planning
services as a solution. This difference, however, was
to affect the relationship between government and
non-government population organizations in future
years, as their paths diverged more often than not,
and initial compatability of views gave way to open
discord.
The glamour years (1965-1969)
I. Ayub cultivated his demographic fascination in
discussions with economists from the Planning Com-
mission and meetings with the fast-growing FPAP.
When FPAP held its first-ever national seminar in
February 1959, Ayub attended and spoke forcefully
about the 'menace of over-population' which was
destined to lead to a standard of living 'little better
than that of animals' (Pakistan Times, February 25,
1959). A National Board of Family Planning was
established at the federal level, with two subsidiary
organizations for East and West Pakistan respect-
ively. The Board advised the government on policy,
while the ministry of health implemented the new
campaign. Personnel were trained and cheap con-
traceptives distributed through government hospitals
and voluntary organizations such as FPAP. Saeeda
Waheed and Alamgir Kabir, then Vice-President of
FPAP, joined the Board along with senior health
ministry and planning commission officials.
The reasons for Ayub Khan's position are varied, but
a few stand out because of the effect they had on the
programme as it evolved into the 1990s. First, the
role of religion in his government was not signifi-
cant. Ayub Khan was a Sandhurst-educated military
dictator with little personal concern for the religious
position on family planning. Unlike General Zia who
was to be the country's next long-term military dic-
tator (1977-1988), Ayub did not seek a religious
mandate for his rule. In his address to the FPAP
seminar in Lahore mentioned above, he made a com-
ment that Zia would have considered blasphemous.
'I cannot believe that any religion can object to
population control,' he said, 'because no good
religion can object to anything aimed at the better-
ment of human lot, because all religions, after all,
come for the good of the human race and human
beings do not come into the world for the religions'
(Pakistan Times, February 25, 1959).
When Ayub Khan was overthrown in a popular
movement in 1969, religious parties who joined in
the protest used the population programme to
discredit him morally. In demonstrations they
chanted, 'Family planning, for those who want free
sex!' and burned the programme's publicity hoar-
dings. In 1971 the elected government of Zulfiqar
Ali Bhutto was thus careful to avoid the same
religious rancour, and General Zia, who relied on
the support of religious parties, froze the programme
when he first seized power.
The second reason for Ayub's position was the in-
fluence of the development ideology of his time.
Economic growth, modern industrialization, higher
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
3. 32 Ayesha Khan
per capita incomes - these were the catchwords of
progress in the 1960s and the source of Ayub's
political legitimacy. He was a 'military modemizer',
encouraged to wield his undemocratic powers to
effect strong, possibly unpopular programmes in the
name of economic growth alone (Finkle 1972:
109-10). Government economists and academics
from Harvard University, who assisted the Planning
Commission in designing both the First (1955-60)
and Second (1960-65) Five Year Plans, urged the
government to recognize that even a 1.4% rate of
population growth was a threat to economic progress.
Ayub Khan took serious note of these early warnings
but found himself frustrated in his search for a quick
solution.3
Pressure was building on Ayub Khan to show that
his programme of intensive industrialization was
reaping tangible benefits in improving the standard
of living of Pakistanis. The West expected Ayub to
fulfill his promises of economic development, and
praised him lavishly when he was seen to succeed.
'The survival and development of Pakistan is one of
the most remarkable examples of state and nation
building in the post-war world', wrote The Times of
London in 1966 (as cited in Hasan 1986:88).
The third reason for Ayub's position on family plan-
ning was its political utility. He was a military dic-
tator of a poor country, in search of a development
strategy, and without any popular mandate to his
leadership. Like all other rulers of Pakistan, he relied
on support among the landed elite and monied
business houses to stay in power, despite promises
in public that sweeping land and social reforms would
take place. Wajihuddin Ahmed, later Commissioner
for Family Planning, suggests that when Ayub went
to the US in 1959 and requested the oral pill for his
population control activities, he was actually using
the Malthusian scapegoate as a substitute for any
substantial socioeconomic reform programme. By
the mid-1960s, when Ayub was pushing ahead for
rapid industrialization and economic growth, he
hoped that the 'eye-wash' of land reform and popula-
tion control would work as a solution for the
maldistribution of wealth.4
Later governments had to contend with the demise
of the notion that simple industrialization, matched
with controlled population growth, would lead to
economic and social development. In view of the
failures of Ayub's policies, population control on its
own came to be seen as a superficial and risky solu-
tion to the intractable problems faced by subsequent
governments. Both Bhutto and Zia were to advocate
it only when other religious, political, and financial
factors coincided favourably. In contrast with Ayub,
they did not rely on the ideology of modem economic
progress to establish credibility with the people. Bhut-
to was a popular leader, adored by the majority for
his charisma and socialist rhetoric, who came to
power democratically. Zia deliberately contrasted his
rhetoric to secure the support of Bhutto's opponents.
He chose the ideology of Islam to give his govern-
ment legitimacy, and thus the religiously sensitive
notion of family planning was slow to find a place
in his plans for the country.
The fourth important reason for Ayub's enthusiasm
came from abroad. Donor support was critical to
transforming his ideas into a national population pro-
gramme, and it has continued to play a pivotal role
in sustaining it ever since. As early as 1959 he visited
the United States, fully aware that the West regarded
him as a mild, modern, even progressive dictator
(Myrdal 1968: 327). President Eisenhower, whose
opposition to state interference in family planning was
known, refused Ayub's request for the oral pill,
which at any rate was not yet available for widespread
use. Not to be deterred, he went to the Population
Council in New York and requested an advisory mis-
sion to help his government design a family planning
programme (Notestein 1968: 555).
Thus non-government research and technical
assistance comprised the first donor input into the
government programme. The first population seminar
organized by the MOH and the Pakistan Institute of
Development Economics in November 1959 was
attended by Dr MC Balfour, who also assisted
the government in preparing its first strategy.3
Malthusian doomsday theories were debated at the
seminar alongside the ideas of Ansley Coale and EG
Hoover's famous 1958 book, Population Growth and
Economic Development in Low-Income Countries. It
argued that population control would allow families
to accumulate more money for investment and
thereby solve the problem of insufficient capital in
poor countries.
USAID was poised to enter the Pakistan programme
only when Lyndon Johnson came to power and the
US Agency for International Development convinced
him that rapid population growth would undermine
the effectiveness of all other development aid in poor
countries. Meanwhile Ayub was ready to launch a
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
4. Population policy in Pakistan
Table 1. Family Planning Scheme for Pakistan during Third Five-Year Plan, 1965-1970
33
Targets Objectives Implementation
Prevent 5-6 million
births in next 5 years.
Reduce annual birth
rate from 50 to 40
per 1000 by 1970.
Cover all 20 million
fertile couples with
services by 1970.
Maintain present and
planned level of
increase in per capita
income.
Obtain self-sufficiency
in food, avoid imbalance
in age structure of
population.
Massive media publicity, as
part of public-relations
orientation of Scheme, instead
of mainly clinical bias.
Motivation at individual and
village level through contact.
Motivation by bringing supplies
and services to doorsteps of the
people.
Use of monetary incentives.
Employment of 50 000 village
dais; doctors, and health
visitors.
Promotion of foam, condoms
and sterilization. IUDs as major
programme method.
Administrative organization:
Central Family Planning Council, along with Provincial and District Family Planning Boards, and
Union/Thana Councils to carry out implementation. The principal executive is the Family Planning
Commissioner, also Secretary in the Ministry of Health. The Council functions as a semi-autonomous
government body under the Ministry of Health, Labour and Social Welfare.
Major donors during this period:
USAID, Ford Foundation, Population Council (funded by Ford and USAID), University of California
(Berkeley), Johns Hopkins University (funded by Ford), Swedish International Development Agency,
International Planned Parenthood Federation.
full-scale, nation-wide campaign, although he had
failed to receive support from the US for distributing
the oral pill. Valuable lessons had been learned from
the Second Plan activities implemented through the
MOH, which indicated that the health infrastructure
was too immature to take on family planning (United
Nations 1969: 126).
n. Pakistan's first comprehensive Family Planning
Scheme (Table 1) was included in the Third Five Year
Plan (1965-70). In 1964 the Population Council sug-
gested to Ayub's high-level officials that it was time
to launch an independent family planning programme.
On the basis of these recommendations Ayub took
the decision not to rely on clinical services through
the health infrastructure alone.6
The Scheme's ra-
tionale, however, remained government's vision of
economic progress through increasing per capita
incomes. Of particular concern was the lack of ade-
quate food-grains, expected to deepen with population
growth.
Details of this historic programme are of interest
today since future family planning strategies became
variations on the original Scheme (Robinson 1966,
1978, 1987; Shah 1979; Rukanuddinetal. 1992; UN
1969). Its most outstanding feature was its strong
political backing, due to reasons argued above, which
brought a level of credibility and publicity to family
planning which has never been achieved again
since. As a consequence of the money and hype, the
Scheme's only tangible success was to raise aware-
ness and knowledge throughout Pakistan about con-
traceptive availability (United Nations 1969). On the
ground, it suffered phenomenal problems of im-
plementation. Some of the major flaws were: cen-
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
5. 34 Ayesha Khan
tralized administration with an over-dependency on
key individuals, alienation with the health ministry
and consequently other departments, over-ambitious
targets and an extreme supply-side bias.
The man in charge of making it worth the Rs.284
million allocation was Enver Adil, a dynamic civil
servant who adopted what FPAP was later to criticize
as 'the steam-roller approach'. Enver Adil was an
ambitious man whose government career could soar
if he won Ayub's praise. Under pressure, he boasted
of too much success. 'During the year 1967-1968,'
he wrote, '. . . [Our] Concept of standard of living
and per capita income became meaningful as well as
significant and the small family realised as a concrete
means and manifestation of that objective' (Adil 1969:
10). The 1969 UN/WHO report, along with USAID
and World Bank evaluations, also praised the
programme's successes (Pakistan Family Planning
Council 1969: 4-11).
It was a crash programme, designed to have a wide
impact in the shortest time possible. This would
justify the choice of Adil and his steam-roller
approach, the autonomous and costly programme,
and the political backing of Ayub. Full-time staff in-
cluded 1392 Family Planning Officers, 1200 Lady
Family Planning Visitors, and 1209 Family Plann-
ing Assistants. Among the part-time staff were 25 000
traditional birth attendants, who earned referral fees
for clients they brought in (Ministry of Health 1965).
The tale of target-setting reveals the enormous
pressure which Adil was under to prove that his pro-
gramme was doing well. The Scheme set out to
reduce the birth rate from 50 to 40 per 1000 by 1970,
although the Planning Commission had provided a
mistakenly exaggerated figure of 50 to Adil. Over-
ambitious targets forced programme staff to find
creative ways of providing measures of success to
the Planning Commission; measures of 'numbers of
births averted' and 'couple-years of protection', relied
on by the government until today, are a direct result
of an instrinsically supply-driven programme (Bean
and Seltzer 1968).
There was an obvious discrepancy between official
claims and the first research findings. The National
Impact Survey (1968-69), conducted by the federal
Council's Training, Research and Evaluation Centre
(TREC) and assisted by Johns Hopkins University,
revealed that three years after the Scheme began, only
6% of married women were using any contraceptive
method (Shah 1979: 164). It also showed that the
level of IUD use and retention was much lower than
the government had estimated. It suggested a wider
range of contraceptives to be offered to the public,
and a greater emphasis on outreach and motivation
in order to reduce the gap between knowledge and
practice (TREC, nd: 70-71).8
The Scheme brought with it an autonomous admin-
istrative and financial organization, with implemen-
tation at die Union Council level linked with the civil
administration. A separate Division was created under
the MOH. This policy-level office was headed by the
same person in charge of programme implementation,
the Family Planning Commissioner - Enver Adil.
Provincial Family Planning Boards, headed by their
health ministers, were responsible for implementation
that was further sub-allocated to the local levels. Yet
policy-making and basic responsibility for achieving
the targets rested with die federal government,
mereby restricting ownership of die programme to
a small sphere alone. The great show of donor sup-
port, with population programme staff offered sal-
aries higher than other government employees,
created resentment within government against die
programme.
Although at the outset condoms were the most
available contraceptive method, by 1966 die IUD
became the corner-stone of the Scheme. It was
considered the ideal contraceptive: safe, cheap,
reversible, and requiring little user action. Even inter-
national planners expected the IUD alone to reverse
fertility trends (Finkle 1986: 102). Population coun-
cil experiments conducted in Karachi's new National
Research Institute of Family Planning were showing
diat it had a high retention rate and few side effects.
Incentives were paid for every IUD inserted, as a con-
sequence over-reporting and allegations of financial
misuse ensued. Poor follow-up helped to spread fear
and misinformation about contraceptive side-effects.
The experimental nature of die Scheme did allow it
to respond to some problems as tiiey were discovered.
For example, the focus on IUDs necessitated a change
in the programme, and traditional birth attendants
were almost fully replaced by a new cadre of para-
medical Lady Family Planning Visitors to serve as
IUD inserters. In May 1968 Ayub Khan issued a
directive to enlist the services of medical facilities
and doctors for contraceptive distribution, which
could never be fully implemented because his govern-
ment fell soon after.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
6. Population policy in Pakistan 35
In search of a strategy (1970-1977)
I. Ayub Khan was overthrown in 1969 through
agitation organized jointly by the left-wing Pakistan
People's Party and the right-wing religious parties.
He was replaced by another army general, Yahya
Khan, whose regime did little more than oversee the
civil war which divided East and West in 1971.
Wajihuddin Ahmed replaced Adil as Family Planning
Commissioner during Yahya's rule, and retained
his extraordinary amount of individual policy-making
and programme-implementing power. He designed
an experiment which, if successful, was supposed to
improve implementation and re-orient the programme
from a supply to client-based approach. Wajihuddin
wanted to focus on keeping women non-pregnant,
rather than meeting contraceptive targets alone. He
also arranged for the oral pill to become available
for use in Pakistan, another necessary departure from
Adil's IUD-based Scheme because the poor follow-
up and over-promotion of this method had made it
controversial. Despite his different approach, he
shared with his predecessor a view that family plan-
ning could be delivered to the people through an
effective administrative machinery.9
These ideas were tested in a pilot project known as
the Sialkot Experiment. It began in 1969 and served
as the basis for the Continuous Motivation Scheme
(Table 2) launched nation-wide in 1973, when the
initial healing of war wounds allowed for a renewed
focus on family planning. During this period, the
international debate was raging over whether demo-
graphy could or could not be changed through family
planning activities. Wajihuddin claims the Sialkot Ex-
periment was designed to prove one side false.
Technical and material assistance for the Sialkot Ex-
periment was readily available from Johns Hopkins,
Berkeley, the Population Council, and USAID.
Initial results of increased contraceptive preval-
ence at Sialkot delighted foreign and local experts
alike. The final push to turn Sialkot into national
policy was easy enough. Since Wajihuddin was both
Commissioner in charge of implementation, and Joint
Secretary in the Ministry of Health and Family Plan-
ning, the decision to expand his concept of field
Table 2. Continuous Motivation System and Contraceptive Inundation Scheme (1970-1977)
Targets Objectives Implementation
Reduce birth rate from
45/1000 to 40/1000
(in original Fourth
Plan, 1970-1975)
34% of married women
will practice effective
contraception by 1975
9.6 million births
prevented
Maintain a growth rate
in GNP higher than
population growth
Rapidly reduce fertility
Double expenditure from Third
Plan
Replace use of dais with male/
female motivator teams
Emphasize sterilization and oral
pills rather than only IUDs
Withdraw incentives and
referral fee system
Integrate health and family
planning services at union
council level
Expand CMS and add
inundation scheme
Administrative organization:
Structure of 1965 Scheme retained with changes at the local level. For example, country was divided
into operational units of 8-12 000 population, with male/female motivator teams assigned to each
area. They were supervised by one family planning officer for every 6 teams.
Major donors: USAID, UNFPA.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
7. 36 Ayesha Khan
motivation from Sialkot into other districts nation-
wide was largely his alone to make. Young demo-
graphers working on the Sialkot Experiment sug-
gested the expansion was premature, but they were
ignored in the haste to find another crash programme
as dramatic as the 1965 Scheme.
The civil war intervened to delay the nation-wide
launch. The country split apart and international
assistance was suspended because of army atrocities
in Bangladesh. When Zulfiqar Ali Bhutto's People's
Party took over government in 1971, the new govern-
ment was left with little more than unserviceable
international debts. Bhutto's first priority, like every
leader in Pakistan, was to stay in power. Since the
anti-Ayub agitation had negatively politicized family
planning, Bhutto avoided giving the religious right-
wing an opportunity to use the same slogans against
him. Further, the new government based its popu-
larity on being anti-Ayub and representing the
opposite of the pro-American and capitalist stance
associated with the former dictator.
Unlike Ayub, Bhutto lacked an outright political or
ideological interest in population control, but this did
not tally with the thinking of USAID at the time.
Joseph Wheeler, Chief of Mission of USAID in
Pakistan between 1969 and 1977, recalls, 'It was clear
by 1969 that the issues of the coming decade were
population growth and East Pakistan rice. Clear to
me, that is. From Pakistan's point of view the issues
were different. . . . USAID felt population was an
important issue and offered help.'10
Mubashir
Hasan, Bhutto's first Minister for Finance and
Economic Affairs, recalls that the first overture was
too soon after the war, and government priorities
were rebuilding the army and finding funds without
recreating Ayub's dependency on western aid."
This was not to last long, as Bhutto soon discovered
that the government could hardly fulfil its socialist
promises through financing services it could not
afford. He took up the offer of assistance in popula-
tion by calling a committee to review the programme
as a whole. The Aslam Committee (1972-73),
chaired by the Health Minister, re-approved the CMS
as the national programme for family planning. The
Committee's impact was strengthened as the results
of the 1972 Census were made public; they revealed
that Pakistan's poulation had grown from 43 million
in 1961 to 65 million, and fertility levels remained
unchanged (USAID 1975: 2). The Aslam Commit-
tee also recommended basic infrastructural changes
which were never implemented, such as the complete
federalization of the programme under the Ministry
of Health, and the liberalization of abortion laws,
raising of the marriage age for women from 16 to
18 years, and close association with social welfare
organizations (Committee 1975: 23-24).
n. When USAID resumed full-fledged economic
assistance to Pakistan in 1973, its own Foreign
Assistance Act required it to support 'growth with
equity', and thus the new focus became agriculture
and the social sectors. Between 1964 and 1979, the
year USAID suspended aid to Pakistan for political
reasons, it had spent over $30 million on Pakistan's
population programme; during 1965-75 USAID pro-
vided 40% of total programme inputs (CDIE draft,
1993: 8).
'America cared [about population] because there was
commitment from the highest level down that rapid
population growth was a hindrance to development
in the Third World,' explains Steven Sinding, who
served in Pakistan's USAID population project from
1974 to 1978 and later rose to head USAID's Office
of Population in Washington DC. He adds that this
view has usually been strengthened with Demoratic
leadership in the White House and weakened during
Republican regimes such as Reagan's, which sought
to appease religious and right-wing lobbies at home
by de-funding USAID's population activities."
USAID's 1973 population project was rooted in this
policy context, yet its stated goals in Pakistan were
somewhat mixed. Its original purpose was a broader
institutionally-oriented focus, whereas the USAID/
Islamabad mission prioritized the delivery of con-
traceptive methods (CDIE draft, 1993: Annex; 3).
$20.6 million were provided for contraceptive sup-
plies, in support of a major new addition to CMS -
the Contraceptive Inundation Scheme (Table 2).
Wheeler claims Inundation was intended to ensure
a choice of family planning methods, 'which could
only be achieved if public/private supply lines were
full and maintained.'12
Inundation was the brainchild of Reimert T
Ravenholt, a senior population officer at USAID in
Washington, who believed that a large and ready
supply of contraceptives would generate more de-
mand for family planning and thus increase con-
traceptive prevalence rates (Ravenholt 1968: 573).
The translation of this thought into practice was, in
Pakistan, 'perhaps the ultimate effort to put into place
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
8. Population policy in Pakistan 37
a supply-oriented program' (Robinson et al. 1981:
87). The plan was for condoms and oral pills to be
distributed through a network of 50 000 shopkeepers,
health outlets, and fieldworkers, to make contracep-
tives easily available throughout Pakistan.
The approach was extreme and unrealistic in its goals,
but it grew out of a very real debate among popula-
tion researchers at the international level. This
became apparent during the 1974 Bucharest Con-
ference on Population, when two views on fertility
reduction diverged. The public health services ap-
proach, to which Ravenholt adhered, was primarily
supply-driven and considered fertility a function of
contraceptives and availability. Conversely, the social
science approach viewed fertility reduction as a func-
tion of a nation's complete development.
Wheeler wanted Pakistan to work simultaneously on
strengthening both the system and the supplies in
family planning.10
Yet the debate continued within
USAID and carried over into its Pakistan Mission.
In 1974 Sinding criticized the Ravenholt approach at
an internal meeting in Washington. He believes that
Ravenholt gave USAID and the US government a bad
name by refusing to acknowledge that population had
other dimensions. Although Wheeler had begun
testing Ravenholt's ideas through the CMS and In-
undation, he invited Sinding to set up a research pro-
gramme in Pakistan to test out these new ideas.
•I. CMS and Contraceptive Inundation were never
implemented as planned; they 'failed', in a sense,
before they were put to the test. This could have been
avoided if internal warning signals were not ignored
in the rush to put in place a nation-wide programme
that would prove to donors and the government that
fertility rates could be reduced through family plan-
ning services.
For example, Wajihuddin Ahmed proposed the
gradual introduction of CMS over five years, but the
war intervened and later the Aslam Committee
approved the all-out expansion in 1973. Dr Attiya
Inayatullah, then a senior member of FPAP, also
recalls telling the government that CMS required
variations for different parts of the country.13
Her
view reflects the micro-perspective on local popula-
tions which comes from NGO work at that level. In
contrast is a government view, still in effect today,
that successful NGO or pilot projects can be repli-
cated without subtlety across Pakistan's extremely
heterogenous population. Linked with this is another
government view, held from Adil's era until today,
that family planning is an administrative matter. The
bureaucracy's failure to carry out the inter-personal
motivation envisaged in the CMS is thus no surprise.
Meanwhile, Contraceptive Inundation suffered from
a logistical problem. USAID procured the supplies,
but the system of distribution to outlets, many of
which existed only on paper, never took off. After
two years of Inundation, the programme was able to
reach only 15% of the market in the commercial
sector. With the central warehouse in Karachi over-
flowing, the reported condom user figures were ex-
aggerated (CDIE draft, 1993: 10). In terms of
increasing knowledge and access to contraceptives
among the population, and reducing the growth rate
from 3%, the 1975 Pakistan Fertility Survey revealed
that little had changed over the last 7 years (Robinson
et al. 1981: 88).14
The problem of over-centralization was not solved
either. From 1976-77, the programme became fully
federalized. The Population Planning Council in
Islamabad became a division under the health
ministry, with provincial organizations made depart-
ments under Health at that level. The federal govern-
ment was charged with policy formation and
financing of the programme, while the provincial
departments were to implement it. Financing, as
always, was to come from the centre. Finally, higher-
ranking employees in population were made full
government servants in an effort to improve their
status within the civil service.
The relations between population and health became
even more strained during the Bhutto period. The
above-mentioned moves to 'bi-furcate' the pro-
gramme when population became a division with a
separate Secretary under the MOH further alienated
population from health services. The result was that
the individual power of the new Secretary within the
civil services was undisputed, true to the tradition of
the programme leadership thus far, and this amidst
growing hostility to population from surrounding
government departments.
By this time USAED had developed its own misgiv-
ings. From 1973 to 1981 cumulative commitments
of USAID in all sectors totalled $5.1 billion. Out of
its 1973-77 Population Planning project, the Inun-
dation Scheme was its largest single budget item,
although 'no comprehensive analysis such as market-
ing and economic studies was made to determine the
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
9. 38 Ayesha Khan
effect of inundating Pakistan before [US]AID com-
mitted funds' (CDIE draft, 1993: 5-8). This suggests
that although the donor role in Pakistan's programme
had grown enormously during the Bhutto era, it was
not very effective or responsible. USAID, with many
dollars to spend, rushed its Inundation Scheme
although it was obviously supply-focussed and in con-
tradiction to the CMS client-based approach.
There was deep donor disillusionment with Pakistan's
management as well, with the 1976 USAID evalua-
tion concluding that CMS had not increased delivery
of contraceptives effectively, the government had not
managed the huge population investment in line with
any comprehensive national strategy, and that despite
growing expenditures there had been no decrease in
fertility over the last 10 years (CDIE draft, 1993: 8).
Wheeler states, 'In retrospect I think one could say
that USAID made a high risk bet that government
management and political support would match
generous US assistance. We lost that bet. But the
issue is of such importance that in my view, it was
right to try.'10
By 1977 USAID was prepared to resolve some of the
manifold problems within its own Pakistan project
by finding innovative ways to create demand for ser-
vices, and studying how alternative determinants of
fertility could be addressed through the public sec-
tor in order to reduce growth (CDIE draft, 1993: 10,
Annex: 11). If it had succeeded, it might have stimu-
lated debate in Pakistan over how causes of high fer-
tility, rather than merely the phenomenon of frequent
child-bearing, could have been addressed by the na-
tional population programme.
However, by this time the Bhutto government was
tottering. The opposition movement included in-
dustrialists and middle-class traders disillusioned with
Bhutto's policies, and given a strong voice by
religious leaders. Population became more sensitive
and even less of a priority than ever. Bhutto first tried
to appease the new pressure groups by declaring
Friday, instead of Sunday as a national holiday, and
banning alcohol. This pattern of granting symbolic
concessions to the religious right-wing began under
Bhutto and was taken to its greatest extreme by
General Zia ul-Haq, the Chief of Army Staff, who
deposed Bhutto and declared martial law in 1977.
The programme persists (1977-1994)
I. The present key period in Pakistan's population
programme is the longest and most complex thus far.
With the government of General Zia ul-Haq, factors
influencing policy-making which were already woven
into the Ayub and Bhutto periods now became exag-
gerated and explicit. Whereas Bhutto and Ayub suf-
fered the interference of the religious right-wing with
their ideologies of politics and development, Zia
made the religious right-wing his political ideology.
He used the conservative middle-classes and religious
lobbies to win initial support for his military take-
over. His rule was designed to negate the ideology
of Bhutto's People's Party, and over time break the
popular support base which Bhutto enjoyed despite
his fall from power.
Zia froze the population programme when he first
assumed power in 1977. One stated reason for his
decision stemmed from the widespread belief that
Bhutto had used PPP workers as field motivators. All
political activity, including anything that could
possibly have mobilized the public in favour of Bhut-
to, had to be suppressed by Zia during the early, and
most fragile, period of his rule. His subsequent ban
on publicity for family planning activities was one
of many gestures to his religious constituency, tradi-
tionally opposed to birth control programmes, that
he was serious about Islamization.
Women became the symbol of his ideology. In 1979
he promulgated a series of Hudood Ordinances
prescribing punishments for theft, rape, intoxication,
and adultery, according to Saudi Arabian interpreta-
tion of Islamic law (Wahhabi'ism). Sex outside mar-
riage became a crime against the state, punishable
by death. Until today, fornication and rape are not
treated separately, and the onus of proof of innocence
on the first charge lies with the woman, and as for
the second, if she cannot prove she was raped she
becomes liable for charges of adultery. Jails became
filled with women accused by their menfolk of
adultery. Although the maximum punishment was
never carried out, it caused an increase in violence,
especially state-sponsored attacks, against women and
a deep sense of insecurity took root among them
(Jehangir and Jilani 1990).
The international-level debates on population issues,
which had earlier prompted experiments in Pakistan,
were now subsumed in importance to the crude
political agendas not only of government but the
donors as well. USAID's assistance was suspended
twice during these years of political crisis and harsh
military dictatorship. First, from April 1976 to
September 1978, assistance was frozen as a result of
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
10. Population policy in Pakistan 39
Pakistan's nuclear programme. Second, from April
1979 to 1981, assistance was banned following the
burning of the US Embassy in Islamabad and political
differences between the US government and
Pakistan's military regime.
Zia's process of Islamization and human rights abuses
initially alienated him from the Western powers that
Ayub Khan had so carefully cultivated. If die inva-
sion of Afghanistan by Soviet forces in December
1979 had not suddenly made Pakistan a strategically
important country for die United States, it is unlikely
that his regime would ever have received international
political and financial support. As it turned out,
money flowed in during the 1980s for population as
part of Pakistan's obvious reward for playing the Cold
War game to the tune of the West.
With population policy more grossly subject • to
political manipulation and donor support than ever,
problems with the programme only deepened, par-
ticularly in regard to its over-centralization, its rela-
tionship with health, and the role of non-government
organizations. When Zia allowed the programme to
restart in 1980, efforts began to resolve these issues
despite obvious impediments. These remain even
after the resumption of elected government in 1988.
In 1980 Zia put Dr Attiya Inayatullah of FPAP in
charge as Advisor on Population. She had a wealdi
of experience in delivering services effectively on
the non-government level, and understood the link
between fertility reduction and improvement in
women's status. However, her effectiveness as Zia's
advisor was clearly undermined by the increased
vulnerability of Pakistani women caused by the very
government she now represented.
Yet the appointment of a high-profile, competent pro-
fessional suggests Zia was making a firm commit-
ment to finding long-term solutions to intractable
problems and involving NGOs in the process.
Inayatullah claims mat Zia gave her a 'blank cheque'
to do as she wished. Dr Mahbub ul-Haq, Minister
for Planning and Development and Minister in charge
of the Population Division from 1982-86, says the
only instructions he received from Zia were to quiedy
go ahead with the programme without involving the
President.13
Zia himself did not advocate family
planning publicly, nor did he allow effective media
campaigning. Therefore the government was actually
minimizing its risks. Zia reinforced the tradition of
appointing high-profile individuals to put an effec-
tive face on a programme which the government did
not know how to institutionalize or stabilize.
Speculation persists about his motives for re-
launching die programme at all. For example, John
Blackton, with USAID in Islamabad during the
1980s, argues that Zia was under external pressure
from the United Nations, USAID and the World Bank
to show that something was being done in primary
education, health and population. He says the appoint-
ment of Dr Inayatullah 'was a frequent device of the
Government to put someone in place to make it seem
like somediing was happening'.16
The availability of
funding possibly increased Zia's tolerance, as sug-
gested by Dr Haq's comment: 'I could sense I could
get any amount of money any time from [donors]
for population'. The appointment of Dr Nafis Sadik
as Executive Director of the UNFPA in 1987, which
had to be approved by her own government, helped
to boost die government's image at home and abroad
that it was serious about population.
When USAID moved back into Pakistan in the wake
of changed political realities, it was eager to make
friends with General Zia's military regime. In 1981
a $3.2 billion aid package, half of it for military
assistance, was negotiated for the period 1982-87
(CDIE draft, 1993: 6). The Project Paper for
USAID's $25.6 million grant for Population Welfare
stated: 'The military-security-political position of
Pakistan, including the burden of a massive [Afghan]
refugee influx, accentuates die development problem
to which the proposed US economic assistance
package responds' (USAID 1982: 7).
USAID was not involved during the reconceptu-
alization of Pakistan's population strategy, which in
part explains why their own input during the 1980s
did not reflect any major innovation or rediinking on
tiieir part. The $25.6 million was enhanced by anotiier
$14.4 million in 1986 to purchase additional con-
traceptives for the project. $45 million were further
allocated during the project period, to support the
Social Marketing of Contraceptives, a more sophis-
ticated version of Inundation. Contraceptive supplies
remained USAID's largest input into the programme,
despite USAID's policy to add training and EEC com-
ponents during the 1980s. At the close of activities,
an internal evaluation concluded that '[US]AID did
not contribute to financial sustainability in the popula-
tion sector' (CDIE draft, 1993: viii).
In retrospect, the political contingencies and context
of US assistance to Pakistan made this harsh verdict
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
11. 40 Ayesha Khan
inevitable. Despite obvious failures in population dur-
ing the 1970s, USAID was politically bound to com-
mit large funds to Pakistan, and its own mandate
compelled it to prioritize population as part of
development assistance. The Pakistan government
knew US assistance would continue flowing in as long
as the US government relied on General Zia to sup-
port their policy on Afghanistan. Those who had most
control over the highest-level financial and implemen-
ting decisions relating to Pakistan's population pro-
gramme did not believe they stood to lose much if
the programme failed.
Zia's fear of religious opposition lessened as the
donor funding began to pour in for the renewed
population programme. A 1984 report issued by the
Council of Islamic Ideology (CII), whose role is to
ensure that the government only enacts legislation
which is in accordance with Islamic teaching, con-
cluded that the population programme in Pakistan
should be abandoned. 'Because of birth control, the
country shall suffer a turn to apostasy, shamelessness,
and sexual corruption on a national level. And the
country will suffer from a shortage of manpower
which is needed for national defence and economic
development' (CII 1984: 81). This report was meant
to be circulated in Parliament, to force a vote outlaw-
ing the population programme because it violated the
Constitution of Pakistan by being against the spirit
of Islam. As with many of the CII's recommenda-
tions, this one too was better left ignored by Zia's
men and never made it to Parliament.
By this time the political reality of Zia's decision to
put Inayatullah in charge did not prevent her from
ambitiously revamping the national population pro-
gramme on an unprecedented scale (see Table 3). In
an unusual broadening of the policy-making process,
the 1983-1987 Sixth Plan programme draft was
studied by a 'Population Sector Working Group' of
leading international experts before it was finalized
(Robinson 1987: 108). UNFPA, influential as the
only donor supporting the Population Welfare Pro-
gramme during the early years of martial law,
recommended that for the vital integration of Popula-
tion with Health, other organizational changes needed
to take place, such as provincialization of the pro-
gramme, reorganization of the federal Population
Division (along World Bank suggested lines), com-
mercial distribution of contraceptives, and complete
regularization of all population staff as government
servants (UNFPA 1979).17
n. Launching a'multi-sectoral strategy'in 1983 did
not transform the Population Programme radically at
the implementation level, but it did present a new
realization that issues of population were best ap-
proached through integrating service delivery with
other development initiatives. The years since then
have been taken up with reworking, stream-lining,
and experimenting further with the basic integrated
and multi-sectoral premise. Outstanding programme
issues, unresolvable in a context of policy formula-
tion still highly subject to political and donor exped-
iency, continue to prevent ambitious plans from
becoming reality.
Merging family planning with health
The Pakistan government seems aware that a merger
between population and health might resolve some
of the manifold problems of bringing family plann-
ing services to the people. Yet the politics of power
within the bureaucracy have so far hindered the pro-
cess of making the idea a reality. In 1978 General
Zia brought family planning activities directly under
the MOH and abolished the separate Secretariat
within Health which was won during Bhutto's rule.
A full merger between population and health was no
easy task, especially since a separate administrative
system for population had been in place since 1965.
Still, the health ministry requested the Planning Divi-
sion to organize a meeting of experts and bureaucrats
from all the provinces in order to work out the
modalities of a phased integration of all components
of health and population programmes. The plan was
never implemented.
It is alleged that USAID argued against the merger
and provincialization on the grounds that the health
infrastructure as well as the provinces were ill-
prepared to take over full responsibility for popula-
tion.18
It is unlikely that USAID was opposed to
integration per se, as the 1976 evaluation mission of
its population project in Pakistan did recommend an
integration with the health sector (CDIE 1993, draft:
10). But, many of the 1976 evaluation recommend-
ations were ignored when USAID designed its new
population project for Pakistan (1982-87).
When Zia shifted the Population Welfare Division
to the planning ministry in 1981, population gained
only part of the intended increase in status. In fact,
the Secretary of the Ministry of Planning and
Development wanted to abolish the Family Welfare
Centres and make health activities the major outlets
for family planning.19
He alleges that the Advisor
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
12. Population policy in Pakistan
Table 3. Details of the multi-sectoral approach as laid out in the Sixth Plan (1983-1987)
41
Targets Objectives Implementation
Reduce birth rate from
40.3 to 37.3/1000 by 1987
Increase contraceptive
prevalence rate from 9.5%
to 18.6% by 1988
Reduce rate of growth
from 2.87 to 2.69 by
1987
If above achieved, then
0.5 million births will
be prevented per year by
1987-88 (Sixth Plan)
Create a holistic approach,
integrate family planning
with development planning
Differential target group
approach, making use of
other infrastructural
opportunities
Demand creation through
using target group
institutions, mass media
and socio-legal measures
to indirectly reduce
fertility
Emphasize NGOs and local
authorities' role, with
implementation responsibility
mainly with provinces
Broaden services of Family
Welfare Centres to include
health and skills training, and
increase their number from
900 to 1250
Stronger institutional emphasis
on research
Utilize public and private clinic
outlets to widen availability,
also include treatment of
infertility
Commercial marketing of
contraceptives to stimulate
demand and increase availability
Administrative organization:
Population Welfare Division, headed by Secretary within the Ministry for Planning and Develop-
ment, of which it is a part. Advisor to President on Population plays major policy-making role. Federal
level also has a National Council for Population Welfare Planning to formulate policy and review
programme. It is chaired by the President and includes senior government functionaries.
Provincial Councils for Population Welfare Planning have key bureaucrats, private sector represen-
tatives, and NGOs as membership, and are chaired by Chief Minister. District Councils are principal
implementors of programme, with District Population Welfare Officer as responsible officer.
Donors: USAID, UNFPA, World Bank, ODA (UK), CIDA.
Inayatullah resisted his idea because it meant the
abolition of the population 'empire'. His accusation
touches a sensitive chord in all population staff to this
day; that is, as bureaucrats their power is increased
if they manage this heavily-funded domain separately
from health, which in turn stands to gain much finan-
cially and in terms of power enhacement from a full
merger.
The issue began to near resolution with a 1985 deci-
sion by the senior-most National Economic Council,
ECNEC. It directed that health personnel be trained
in family planning techniques and that all Basic Health
Units offer the full range of contraceptive devices
(ECNEC 1985). This may have been one high-level
decision in population policy which took place
without donor influence."
But the orders never got to the ground, as evidenced
by Prime Minister Nawaz Sharif s government when
the new national health policy in 1990 repeated the
requirement that all health outlets offer family plan-
ning services (Rukanuddin and Hardee-Cleaveland
1992). The World Bank went one step further and
recommended the full integration of Maternal and
Child Health Services with family planning services
- in recognition of the linkage between high fertility
and infant mortality rates (World Bank 1989:
150-51).
This concept was to become part of wider social sec-
tor strategy as the World Bank assisted the Pakistan
government in developing a Social Action Pro-
gramme in 1992, to integrate all social sector pro-
jects to work towards the combined goals of reduced
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
13. 42 Ayesha Khan
population growth, basic education, rural develop-
ment, water supply, and sanitation. An on-going pro-
blem the Bank identified was the need to mobilize
working level health staff to deliver family planning
services (Ministry of Population Welfare 1993: 1 and
Annex 5:11-12). UNFPA's current Country Direc-
tor, Nesim Tumkaya says the donors and UN System
have been strongly advocating a full merger since the
1990 decision to integrate field services.20
The new government of Prime Minister Benazir
Bhutto took an initiative soon after coming to power
in 1993 to train 33 000 village-based health workers
through the health ministry (Table 4). These female
field staff will provide basic preventive health, nutri-
tion, and family planning services at the village level.
At first it seemed that the Ministry for Population
Welfare was destined to suffer a setback to its own
new village-based family welfare workers' scheme,
but that was not to be, as Bhutto's initiative will be
implemented through the health ministry. The sudden
appearance of an ambitious 'scheme' which creates
many jobs and has not been systematically tested is
reminiscent of Adil's Scheme and the CMS days,
when the government was in a rush to find a project
that would show quick results.
Integration is more likely than ever today because it
is now a conditionality for SAP funding. That is, the
Ministry of Health is required to deliver family plan-
ning services, and donor funding will only follow im-
plementation of this recommentation (Ministry of
Population Welfare 1993: Annex 1:4).
Devolving federal control
The Pakistan government has traditionally operated
within a highly centralized framework. The isue of
devolving federal control to the provinces is extre-
mely politicized and the future of the nation will hinge
largely on how this issue is resolved. The popula-
tion sector has suffered because of this problem, more
so since 1976 when the Programme was fully
federalized. In 1979 UNFPA suggested provincializa-
tion as the first step in the transition towards the full
integration of population with health, which was
already the responsibility of the provinces (UNFPA
1979: 64).
In 1983 Inayatullah set out to begin the process of
provincializing the population programme, because
options were running out. Population had originated
outside government and then joined various federal
ministries without much success, so diat little choice
was left but to explore its luck with the provinces.
Provincial councils were created for population
welfare planning, with district councils as the most
important implementors of the activities (Robinson
et al. 1981: 109). Funding for all population activities
in the government sector, however, remained part of
the Federal budget's Annual Development Plan.
The government reduced the number of staff in
population, in an attempt to create a cadre for popula-
tion workers equivalent to the formalized cadre of
Post and Telegraph within government. After a period
of initial rebellion, existing population staff were re-
quired to take the same Public Services Commission
exam which other government servants must take to
be regularized. Those that refused were fired, and
thus the staff was reduced from 16 000 to 8300.
After this episode, the relations between federal and
provincial population departments became more sen-
sitized. Although the government promised decen-
tralization, it was - and still is - unable to work out
the modalities. According to Inayatullah one reason
is that the Constitution of Pakistan declares popula-
tion the responsibility of the federal government. In
1983 a Presidential Ordinance was issued transferring
field activities to the provincial governments, while
policy-making and finance remained at the centre, as
constitutionally required.
Pressure to proceed with full decentralization, to
bring not only budgetary allocation but also policy-
making to the provincial level, has gained in momen-
tum over the last 15 years. Today the provinces have
little input in policy, they simply adopt the targets
set for the Five-Year Plans by the centre and do their
best to achieve them. Over-centralization of funds is
another problem for provincial population staff, who
rely on the federal government to release money for
even the most minor expenditure at the local level.
The Programme as run from the centre has not been
successful, giving donors reason to push for this
major policy, and legislative, change. To begin, the
turnover of Federal Secretaries within a period of 25
years was almost one per year. With each Secretary
wielding enormous individual decision-making
power, this has often exacerbated the smooth work-
ing of Population with related ministries such as
Health or Education. As UNFPA's Nesim Tumkaya
points out, obstacles to smooth cooperation stem from
individual rather than institutional animosities.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
14. Population policy in Pakistan 43
Table 4. Modifications of the multi-sectoral approach during Seventh and Eighth Five-Year Plans
1987-1998)
Targets Objectives Implementation
Seventh Plan 1987-1993
Lower crude birth rate
from 42.3 to 38/1000
Increase contraceptive
prevalence rate (CPR)
from 12.9% to 23.5%
Prevent 3.17 million births
Accelerated Programme 1991:
Increase in child survival
will help reduce fertility
Overcome inadequacies
in service availability
and involvement of other
government sectors
Reduce infant and child
mortality
Involve all health outlets in
services
Include mobile service units
for areas not covered
Open 45 new contraceptive
surgery centres, train lady
doctors at sub-district level
Launch wider communications
effort, have visible and
sustained political commitment
Eighth Plan 1993-1998
Raise CPR from 14% to
29%
Reduce total fertility
from 5.9 to 5.4
Reduce crude birth rate
from 39 to 35/1000
Prevent 4.66 million births
Reduce population growth
rate from 2.9% to 2.6%
Total programme outreach
to expand from 20% to 80%
of population
Increase rural coverage
from 5% to 70% and urban
coverage from 50% to 100%
Demand creation for
services through
communication
Use 12 000 village-based family
planning workers to provide
counselling, supplies and
referrals
Involve all health outlets and
private medical practitioners in
service provision
Strengthen supervision,
monitoring, feedback at local
levels
Emphasize clinical methods,
i.e. IUD, injectable and
contraceptive surgery
Upgrade IEC and inter-
personal motivation
approaches
Use of private sector through
SMC, hakeems, homeopaths,
traditional birth attendants,
medical professionals
Major donors: USAID, UNFPA, ODA (UK), Asian Development Bank, CIDA, WHO, Social
Action Programme funding, World Bank, European Community (expected)
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
15. 44 Ayesha Khan
Lack of communication within the federal sectors re-
mains a problem, and equally weak are the
provincial-federal communication links.21
The on-
going position of the Population Welfare Division,
since promoted to a ministry in 1989, has been that
the provinces lack the political will and infrastruc-
ture to assume ownership of the Programme (Ministry
of Health 1994). This is partially true, given that
political commitment at the provincial, district, and
local levels is weak for social sectors as a whole in
Pakistan, a problem separate from the high-level
political leadership which is more often viewed as
an indicator of commitment.22
Existing health ser-
vices, administered as a provincial responsibility, are
almost as inadequate as family planning services, in-
dicating that provincially-owned programmes have
no guarantee of success.
Nevertheless, decentralization has become a main
conditionality for World Bank support to Pakistan's
Population Programme. This sector is critical to the
new Social Action Programme, during which federal
and provincial governments, as well as donors, will
coordinate their planning and funding to fit into a
common set of goals. The World Bank has played
a leading role in designing the SAP approach with
the Pakistan government, in an effort to ensure
that future social sector funding will be fully and ef-
fectively utilized to improve human development
indicators.
The World Bank acknowledges the need to phase the
process of decentralization to the provinces with
careful planning. Its inside role in policy design is
illustrated by its assistance to the Pakistan govern-
ment to draw up a schedule of policy issues and
actions to correspond with its wide-ranging recom-
mendations. World Bank assistance to population
from 1995 will take the form of reimbursal for
government expenditure on a given project, a depar-
ture from old-fashioned bi-lateral grants and tradi-
tional loans which have been the mainstay of
population funding and were allocated before they
were spent. The new tone of severity is unmistakable:
'Evidence of sustained implementation progress of
the program (and the associated reform matrices)
under the SAP [Project] would be crucial inputs
when the final decision is made on whether to pro-
ceed with the first year of the PWPP (in the jargon,
they would be key up-front actions)' (Ministry of
Population Welfare 1993: 9).
There are two important reasons why complete
decentralization will still be difficult. First, the
provinces feel the federal government should either
increase the share of its regular provincial allocations
to include population, or it should guarantee separate
funds for population for an indefinite time period.
This is a difficult commitment for the federal govern-
ment, since it regularly readjusts its own budget for
population on an annual basis to cope with exten-
uating circumstances or changing priorities.
Second is the option of making population expen-
ditures subject to the approval of the provincial
legislatures. Provincial parliaments would be free to
adjust the Population Programme to suit their own
local needs and the federal government would end
up with no effective control over population pro-
grammes or policies. Since population is a concurrent
subject in the Constitution, this latter option would
violate its mandate. Recent intimations by the popula-
tion ministry and UNFPA, however, suggest that the
government is planning to resolve the problem next
year via the first option, by giving provinces addi-
tional funds to be used for stipulated population
expenditures only.7
-20
Thus, full ownership of popu-
lation by the provinces will not take place.
Agreeing on a role for the NGOs
The last 15 years have witnessed a slight move to
decentralize control not only within government
bureaucracy but outside it in the non-government
(NGO) and private sectors as well. Considering that
the country is fraught with problems of national
identity, demands for more provincial autonomy,
economic fragility, political rivalries, and so on, the
central government finds itself in the awkward posi-
tion of recognizing its own insecurity and still being
pressured to give over control in the name of larger
national interest.
Some of this power-struggle has been played out in
the population sector, where the main actors -
government, donor, and NGO - have been unable
to strike a workable relationship. In the 1950s FPAP
had the unmistakable lead in guiding the government
on population issues, and during the 1965 Scheme
FPAP and the government developed differences in
approach but continued to cooperate. In still more
recent years the NGO/government relationship has
developed deep, perhaps unresolvable rifts.
The multi-sectoral approach as outlined in the Sixth
Plan envisioned the creation of the Non-Government
Organizations Coordinating Council (NGOCC) to in-
stitutionalize the role of NGOs in population. The
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
16. Population policy in Pakistan 45
government was to fund this new council and pro-
vide it secretarial support at the Population Welfare
Division. The government took the largest risk with
this experiment. While FPAP and smaller NGOs
stood to gain from more readily accessible funds and
encouragement to set up family welfare projects, and
donors such as USAID could broaden their support
and outreach to NGOs through a coordinating coun-
cil, government was unaccustomed to giving over
control. Thus, the Population Welfare Division ap-
proached the NGOCC with its usual administrative
eye and set impossibly high targets for the numbers
of family planning outlets it was to fund in the NGO
sector for each Five-Year Plan. This restricted
NGOCC's flexibility and minimized the risk that it
would spin off on a different tangent of programme
or policy.
The first donor to provide funds was the Canadian
International Development Agency (CIDA). It gave
an initial $400 000 to make up for a shortfall bet-
ween stated government allocations to the NGOCC
and actual funds available for the year 1985-86. This
was the first sign that government was not fully sup-
porting the new institution. The earliest evaluations
of NGOCC revealed that it was under-staffed, lack-
ing the requisite skills to manage its finances and to
monitor and evaluate the NGO projects receiving
funds (Khan 1994). These serious institutional
weaknesses were acknowledged by CIDA, and
although they remained, no party involved with
NGOCC worked to strengthen it until 1990. CIDA
continued to fund it with $500 000 per year for three
more years. By 1989 NGOCC had expanded its net-
work to include 139 NGOs receiving its funds to
operate 550 service centres. USAID, UNFPA, and
several international donors stepped in, but the
demand always exceeded available funding. Given
the immense institutional weaknesses of NGOCC, it
is no surprise that its achievements fell short of its
targets (Population Technical Assistance Project
1991: 37).
Prime Minister Benazir Bhutto's government an-
nounced in 1989 that NGOCC was corrupt and spen-
ding funds illegally. At the same time it became
widely believed among donors and NGOs that the
new government was using NGOCC to fund
organizations for political purposes. CIDA ordered
an audit of NGOCC's accounts, and although no
financial misappropriation was discovered, it did not
commit further money to the experiment.
The NGOCC mandate expired in 1993. The next con-
troversy began over the form of its reconstitution.
UNFPA, ODA (UK), and the European Community,
which is offering $7 million to fill in the gap left by
USAID, all strongly push for NGOCC to be re-
constituted with full autonomy from the government.
It is a very strong joint NGO and donor position that
NGOCC be able to function without interference from
the Ministry for Population Welfare and that it receive
a steady source of funds.20
A compromise position
has been reached with the ministry for NGOCC to
be reconstituted with a government endowment, in
place of annual budgetary disbursals, and minimal
official involvement.
Yet freeing NGOCC from close government control
may not resolve the underlying mistrust between the
government and NGO sector, especially since the
government has proposed new legislation to curb the
independence of NGOs. Attiya Inayatullah believes
that the government feels threatened by the NGOs
'out of its own incompetence' and its inability to
organize the social sectors. Dr Siraj ul-Haq explains:
'NGOs in the long run can change the social set-up
and that is what the government is afraid of. If the
threat does run this deep, then even donor pressure
to extricate the NGOCC from federal control will not
turn the relationship between the two sectors into a
partnership of development, as envisaged by NGO
leaders and advocated by donors.
A thorough assessment of what has gone wrong
within government, donors, and the NGO sector
would have to critique the persistence of donors in
funding projects despite poor results and evaluations.
The donors' preference for the non-government sec-
tor is linked with three issues. First is that govern-
ment does indeed feel threatened by the NGO sector.
Second is that this problem is being accommodated,
not resolved, by donors' insistence that the reconsti-
tuted NGOCC be fully autonomous; allocating ma-
jor funds to it while it lacks the capacity to utilize
them effectively would demonstrate the same ir-
responsibility of the first experiment. Thirdly, if
blame is to be apportioned for lack of support to
NGOs in population, then donors must carry the
burden along with the population welfare
bureaucracy. They have funded the government pro-
gramme heavily since its inception and thus have
closely nurtured the fundamental 'administrative' and
supply-based approach towards population planning
in Pakistan that is proving such a hindrance to its suc-
cess today. The turn to NGOs for inspiration and in-
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
17. 46 Ayesha Khan
novation reveals how stagnant both government and
its major funders in population have discovered
themselves to be.
In search of solutions
The above discussion has elucidated patterns evident
in Pakistan's population policy on two levels. First
is the political context in which the policy of 'popula-
tion control' has been rooted. This context has been
influenced to varying degrees during the Ayub,
Bhutto, and Zia periods by the role of religion in
politics, the influences of Western donors, the effect
of international development ideology, and the
political utility of the population programme to each
government. Second, over the last 35 years Pakistan's
population programme has been riddled with prob-
lems of implementation that have essentially remained
unchanged. These include an over-centralized and
bureaucratized programme which relies too much on
the power of 'key individuals', a poor working rela-
tionship between the government and non-
government sectors, and a lack of coordination bet-
ween population and health within government. These
deep-rooted structural problems within the pro-
gramme cannot be resolved without addressing the
policy context in which they have evolved.
Through the 1994 United Nations Conference on
Population and Development, the international arena
has sanctioned the need for cooperation between
family planning and health services, and government
and non-government organizations, in order to in-
tegrate human development with reproductive health
concerns. The Cairo Conference enthusiastically en-
dorsed the modern notion of sustainable development,
which views people, especially women, as subjects
and not objects of programmes. Today's population
programmes are thus compelled to reform themselves
in line with the priorities of women's health and well-
being; this means reproductive and child health, and
the enabling legal, social and economic conditions
which make family planning a real and safe option
acceptable to both the state and its citizens (see Sen
et al. 1994). The days of pushing contraceptive ser-
vices as a means to reduce female fertility according
to pre-set demographic targets are officially over;
even Pakistan has signed the Programme of Action
without reservation.
Yet each country has specific policy constraints which
cannot be resolved, despite die best of stated inten-
tions, unless there is a favourable confluence of fac-
tors. In Pakistan, international and domestic agendas
coincided during Ayub's government to produce a
population programme, but one which was a clear
reflection of the top-down, non-participatory ap-
proach characteristic of a military dictatorship. As
the population programme faltered or gained ground
in subsequent years, its working consistently reflected
the functioning of governments obsessed with re-
taining control at the centre, winning foreign funding,
and appeasing religious opposition. In consequence
they limited the human development of women,
restricted NGOs, and stifled public consensus on
policy issues.
As die international development agenda changes, the
policy context in Pakistan may be just responsive
enough to secure foreign funding, but deeper political
transformations need to take place domestically in
order to bring the ideals of Cairo down into the
workings of the population programme. The current
policy context, in which a series of unstable civilian
governments have recently ruled, looks bleak for
serious human development initiatives. Today's
government lives on the edge of bankruptcy, bur-
dened with international debt and the harsh human
consequences of financing restructuring. It is strug-
gling to survive until the next elections under the
threat of another dreaded martial law. Such a weak
government lacks the support of an informed political
leadership and an engaged public, without which it
cannot rethink die logic of its population programme
or address the highly politicized, chronic problems
of implementation.
Conclusion
Today, Pakistan's population programme stands at
a threshold, along with omer programmes in die
social sectors; die time has come where government,
donor, and non-government organizations know diey
must cooperate to achieve tangible results. The story
of policy formulation in population has uncovered
major stumbling blocks which have contributed to the
programme's ineffectiveness. Recent efforts to in-
tegrate social sector planning, led by me World Bank,
may seek to address these key issues of inter-
ministerial cooperation, provincial ownership of pro-
gramme and policy, and partnership widi NGOs, but
diey cannot force harmony. There is a perceived
political price, which Pakistan's leaders have been
reluctant to pay, for implementing a strong popula-
tion programme; and in addition to diis is the much
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
18. Population policy in Pakistan 47
more serious problem of devolving power in
order to implement this, or any other programme,
effectively.
On the part of all the major actors involved in the
policy-making process, there is no evidence that
repeated failures have led to a fresh look at the prob-
lem itself. The World Bank and UNFPA, for exam-
ple, continue to insist upon the severity of Pakistan's
population crisis, and the government repeatedly
declares its commitment to reducing the growth rate.
Agreement on this count has never seemed easier to
achieve, while the problems of implementation ap-
pear to be growing along with the number of people
in Pakistan. NGOs are pre-occupied with the crisis
of inadequate funding and the lack of support they
receive from the bureaucracy, and by and large they
too have adopted the mind-set of 'population control'.
In the absence of a wide-ranging population pro-
gramme which addresses first and foremost the prob-
lems of the population, rather than the number they
represent, policy-makers are bound to find themselves
at a loss for solutions once again. Pakistan's leader-
ship, it appears, has not evolved in its understanding
of population beyond a need to reduce female fertility
and expand family planning services, despite launch-
ing a multi-sectoral programme in 1983. Lack of
tangible success in reducing growth rates may have
led a more responsive leadership to question whether
it was setting forth on the right quest in the first place.
Endnotes
1
Dr Sorayya Jabecn, Managing Director, Family Planning
Association of Pakistan. Interview with author, 1994. All com-
ments by her cited in this article are taken from this session. See
Appendix I for a list of all interviews held by the author in the
research.
2
See Appendix II for a list of all such major political and
legislative events that have affected Pakistan's population pro-
gramme.
3
Wajihuddin Ahmed, Commissioner for Family Planning
1971-1973, as interviewed by author, 1994.
4
Similar suspicion of political rhetoric was once expressed
even before Ayub's era in a 1956 newspaper editorial: 'As for the
argument that the Planning Board set up by Government . . have
recommended the adoption of some sort of check on the popula-
tion, this proves only that much that the Government is quite keen
to shift the blame of our existing poverty from their shoulder to
that of over-population' Gvil and Military Gazette, April 15, 1956.
5
President of the Population Council Dr Frank Notestein sent
some experts in the population field to assist Pakistan. In addition
to Dr Balfour, Dr Harper and Mr W Parker Mauldin assisted in
making an appraisal and series of recommendations, which formed
the basis of the national family planning programme as part of the
Second Five-Year Plan (1960-65) (Sharif 1960: 146).
6
Khalil Siddiqui, former Joint Secretary, Ministry for Popula-
tion Welfare and first statistician in the 1965 Family Planning
Scheme; interview with author, 1994. All comments attributed to
him in this article are taken from this interview.
7
See Appendix HI for budgetary details on family planning
for Five-Year Plans from 1965 to present.
8
Begum Viqar un-Nissa Noon, wife of former Prime Minister
Feroze Khan Noon, was President of Pakistan's Red Cross during
this period. She recalls noting that Adil's claims of IUD acceptance
were exorbitant and higher than the retention rate found in her
own clinics. When she mentioned this to Muzaffar Ahmed, then
Chairman of the Planning Commission, she recalls that he indicated
to her there was nothing he could do about the over-reporting, as
Ayub Khan was too enamored with the good results of the pro-
gramme to entertain any other idea.
9
For a detailed discussion of what became known as 'Waji-
huddin's Approach' see Ahmed (1970) and Robinson (1978). A
critique of its implementation can be found in Robinson et al.
(1981).
10
Joseph C Wheeler, Chief of Mission USAJD in Pakistan
1969-1977. Correspondence with author, April 4, 1994.
11
Mubashir Hasan, former Minister, Finance, Planning,
Economic Affairs 1971-1974. Interview with author, 1994.
12
Steven Sinding, interview with author, 1994.
13
Dr Attiya Inayatullah, current President FPAP. Interviews
with author, January and April 1994. This and all comments
attributed to her arise out of these sessions.
14
The 1993 CDIE draft notes USAID's own views: 'The
failure of the CMS portion of the program was attributed to the
employment of young, unmarried girls as motivators, the high
number of political appointees, and die lack of supervision of the
field effort. Inundation was virtually a lost cause because while
contraceptives were supplied in large numbers to shops, they were
often kept out of sight.' (Annex: 8)
13
Interview with author, 1994. This and all comments at-
tributed to Dr Mahbub ul-Haq in this article are drawn from the
same interview.
16
Interview with author, 1994. Mr Blackton is current Chief
of Mission, USAID Pakistan and Afghanistan.
17
See Robinson (1987) for a more detailed explanation of the
multi-sectoral strategy launched during the Sixth Five-Year Plan.
18
Interview with Dr Siraj ul-Haq, Chief of Health and Popula-
tion at the Planning Division from 1973-1991, and present World
Bank consultant.
19
Ejaz Naik, former Secretary, Ministry of Planning and
Development, interviewed by author. This and all following com-
ments attributed to Mr Naik in the report are drawn from the same
interview.
20
Author's interview with Nesim Tumkaaya, Country Direc-
tor UNFPA, 1994. All comments attributed to him in this report
are taken from this interview.
21
Obaidur Rob, Population Council in Pakistan, as commented
during an interview with author, 1994 (see also Cernada and Rob
1992).
22
MS Jillani, retired Secretary for Population Welfare, as
interviewed by author.
References
Adil E. 1968. Measurement of family planning progress in
Pakistan. Demography 5(2): 659-65.
Adil E. 1969. Pakistan's Family Planning Programme. Paper for
the International Conference on Family Planning, Dacca.
Pakistan: Family Planning Division.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
19. 48 Ayesha Khan
Ahmad, Mahbub. 1993. Country paper on achievement/successes
of the Population Welfare Programme of Pakistan. Regional
Conference on Family Planning, Tehran, September 11-15,
1993. unpublished.
Ahmed, Wajihuddin. 1970. Field Structures in Family Planning.
Islamabad: Population Planning Council of Pakistan.
Bean LL, Seltzer W. 1968. Couple years of protection and births
prevented: a methodological examination. Demography 5(2):
947-59.
Center for Development Information and Evaluation (CDIE),
United States Agency for International Development. 1993.
Evaluation of AID Family Planning Programs, Pakistan case
study. Unpublished draft. Washington DC: CDIE/USAID.
Cernada GP, Rob UAK. 1992. Information, education and com-
munication needs in family planning: the case of Pakistan. In-
ternational Quarterly of Community Health Education 13(2):
97-106.
Civil and Military Gazette, April 15, 1956. Lahore.
Coale A, Hoover EG. 1958. Population Growth and Economic
Development in Low-Income Countries. Princeton, USA:
Princeton University Press.
Committee Constituted by the Prime Minister. 1975. Report on
the Population Planning Programme. Islamabad: Cabinet
Division.
Council of Islamic Ideology (CII). 1984. Report on Family Plan-
ning. (Urdu). Islamabad: Council of Islamic Ideology.
Executive Committee of die National Economic Council. 1985.
Decision of the ECNEC Meeting held on 5th September, 1985.
Islamabad: Government of Pakistan.
Family Planning Division. 1969a. Family Planning Scheme for
Pakistan during the Fourth Five Year Plan Period, 1970-1975.
Islamabad: Government of Pakistan.
Family Planning Division. 1969b. Proceedings of the Pakistan
International Family Planning Conference at Dacca. Karachi:
Government of Pakistan.
Finkle JL. 1972. The political environment of population control
in India and Pakistan. In: Clinton R, Flash W, Godwin R (eds)
Political Science in Population Studies. Lexington Books.
Government of Pakistan, 1960. Outline of the Second Five Year
Plan. Karachi.
Government of Pakistan. 1965. The Third Five Year Plan.
Islamabad.
Government of Pakistan, 1970. The Fourth Five Year Plan
1970-1975. Islamabad.
Government of Pakistan. 1983. The Fifth Five Year Plan
1983-1988. Islamabad.
Government of Pakistan. 1987. The Sixth Five Year Plan
1987-1992. Islamabad.
Government of Pakistan. 1988. The Seventh Five Year Plan
1988-1993. Islamabad.
Hakim A. 1992. Fertility control in the context of the family and
society in Pakistan. Canberra: Australian National University.
Unpublished PhD thesis.
Hasan M. 1986. Alternative to dependence. Future of South Asia.
India: Macmillan Ltd.
MOH, National Steering Committee for Health. 1994. Informal
minutes of working group on population welfare. Ministry of
Health, unpublished.
Jehangir A, Jilani H. 1990. The Hudood Ordinances: A Divine
Sanction? Lahore: Rhotas Books.
Johnson, Jeffalyn and Associates, Inc. 1981. A Review of United
States Development Assistance to Pakistan 1952-1980. USAID,
unpublished.
Khan A. 1994. Summary of CIDA's funding of NGOCC
1985-1988. Prepared on basis of CIDA files viewed by author.
Ministry of Health, Labour and Social Welfere. 1965. Family Plan-
ning Schemefor Pakistan during the Third Five Year Plan Period
1965-1970. Rawalpindi: Government of Pakistan.
Ministry of Planning and Development, Population Welfare Divi-
sion. 1983. Population Welfare Programme, Sixth Five Year
Plan. Islamabad: Government of Pakistan.
Ministry of Population Welfare. 1992. Foreign assistance re-
quirementsfor Pakistan's Population Welfare Programme during
the Eighth Five Year Plan. Islamabad: Government of Pakistan.
Ministry of Population Welfare. 1993. Social Action Programme
Project (Population) and Population Welfare Programme Pro-
ject. Islamabad: World Bank Mission.
Ministry of Population Welfare. 1994. PC-1 Population Welfare
Programme 1993-1998, Federal Activity. Islamabad: Govern-
ment of Pakistan.
Myrdal G. 1968. Asia Drama. New York: Pantheon.
Notestein FW. 1968. The Population Council and the demographic
crisis of the less developed world. Demography 5 (2): 553-60.
Pakistan Family Planning Council. 1969. Annual Report on the
Working of Pakistan's Family Planning Programme 1967-1968.
Rawalpindi: Pakistan Family Planning Council.
Pakistan Times, February 25, 1959. Karachi.
Planning and Development Division. 1978. Proceedings of the Con-
ference on Role of Field Staff of Population Programme.
Islamabad: Government of Pakistan.
Population Technical Assistance Project. 1991. Final Evaluation
of the Pakistan Population Welfare Planning Project No.
391-0469. Washington DC: USAID.
Ravenholt RT. 1968. The A.I.D. Population and Family Plann-
ing Program - Goals, scope and progres. Demography 5(2):
561-73.
Robinson WC. 1966. Family planning in Pakistan's Third Five
Year Plan. Pakistan Development Review 6(2): 255-81.
Robinson WC. 1978. Family Planning in Pakistan 1955-1977: a
review. Pakistan Development Review xvii (2): 233-47.
Robinson WC. 1987. The "New Beginning" in Pakistan's Family
Planning Programme. Pakistan Development Review xxvi (1):
107-18.
Robinson WC, Shah MA, Shah NM. 1981. The Family Planning
Program in Pakistan: what went wrong? International Family
Planning Perspectives 7 (3): 85-92.
Rukanuddin AR, Hardee-Cleaveland K. 1992. Can family plan-
ning succeed in Pakistan? International Family Planning
Perspectives 18(3): 109-15.
Sen G et al. (eds). 1994. Population Policies Reconsidered: Health,
Empowerment and Rights. Harvard Series on Population and
International Health. Boston: Harvard University Press.
Shah NM. 1979. Past and current contraceptive use in Pakistan.
Studies in Family Planning 10(5): 164-73.
Sharif M. 1960. Outlook for government action in family plan-
ning in Pakistan, other Asiatic countries and the Middle East.
146.
Training, Research and Evaluation Centre (TREQ. n.d. National
Impact Survey Report. Lahore: Pakistan Population Planning
Council.
United Nations. 1969. Report on an Evaluation of the Family Plan-
ning Programme of the Government of Pakistan. New York:
United Nations Department of Economic and Social Affairs.
United Nations Fund for Population. 1979. Report of Mission on
Needs Assessmentfor Population Assistance 1979. Islamabad:
UNFPA.
United States Agency for International Development. 1982. Pro-
ject paper, Pakistan - Population Welfare Planning. Washington
DC: USAID.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
20. Population policy in Pakistan 49
United States Agency for Internationa] Development/Pakistan.
1975. Population planning in Pakistan, unpublished.
World Bank. 1989. Rapid population growth in Pakistan: concerns
and consequences. Document of the World Bank, Washington
DC.
Biography
Ayesha Khan is a freelance journalist and researcher based in
Islamabad, Pakistan. She was educated at Yale University, USA,
and the School of Oriental and African Studies, University of Lon-
don, UK. In her writing she focuses on women, health and develop-
ment, with a particular emphasis on population and reproductive
health issues. Her work is published by domestic newspapers and
magazines in Pakistan, as well as foreign news and features ser-
vices. Ms Khan contributed to the 1994 Panos, London, book
Private Decisions, Public Debate, which was awarded the Popula-
tion Institute's XVI Global Media Award for excellence in popula-
tion reporting, awarded at the 1995 World Conference on Women
in Beijung.
Correspondence: Ayesha Khan, #8, St. 8, F-8/3, Islamabad,
Pakistan.
Appendix 1. List of interviews held
1. Ejaz Naik, former Secretary in Ministry of Planning and
Development.
January 3, 1994, Islamabad.
2. Mahbub ul-Haq, former Minister for Planning and Develop-
ment (1982-86).
January 3, 1994, Islamabad.
3. Suraya Jabeen, Managing Director, Family Planning Assoc-
iation of Pakistan.
January 5, 1994, Lahore.
4. Mubashir Hassan, former Minister for Finance and Economic
Affairs (1972-74).
January 5, 1994, Lahore.
5. Attiya Inayatullah, former Advisor for Population to Govern-
ment (1980-8) and current President of FPAP.
January 11 and April 10, 1994, Islamabad.
6. MS Jillani, former Secretary, Ministry for Population Welfare
(1989-91).
January 27, 1994, Islamabad.
7. MA Wasey, Project Officer in USAID (1975-93).
January 23 and 31, 1994, Islamabad.
8. Zeba Zubeir, former Honorary Chairperson NGOCC
(1985-89, 1991-93).
February 2, 1994, Karachi.
9. ImtiazKamal, Director of Pathfinder International (Pakistan)
and former Secretary, FPAP.
February 3, 1994, Karachi.
10. Zarina Fazalbhoy, founder of first family planning clinic in
Karachi.
February 4, 1994, Karachi.
11. Wajihuddin Ahmed, former Secretary for Population
(1971-73).
February 2, 4 and 27, 1994, Karachi.
12. Saeeda Waheed, founding member of Family Planning
Association.
February 24, 1994, Lahore (interviewed by Ruby Bhatti).
13. Steven Sinding, former USAID'Pakistan (1974-78) and
present Director for Population Sciences, The Rockefeller
Foundation.
February 8, 1994, Cairo.
14. Alamgir Kabir, President Family Planning Association of
Bangladesh.
March 2, 1994, Dhaka.
15. Andrew Standley, First Secretary, Delegation of the Euro-
pean Community.
March 10, 1994, Islamabad.
16. Obaidur Rob, Population Council.
March 21, 1994, Islamabad.
17. Lady Viqar-un-Nissa Noon, wife of former Prime Minister
Feroze Khan Noon and former President, Pakistan Red
Crescent Society.
March 24, 1994, Islamabad.
18. DrSiraj ul-Haq, former Chief of Health and Population, Plan-
ning Commission, and current consultant to the World Bank.
March 31, 1994, Islamabad.
19. Khalil Siddiqi, retired Joint Secretary, Population Welfare
Division.
March 31 and April 3, 1994, Islamabad.
20. Baber Hussain arid Lois Bradshaw. Health, Population and
Nutrition, USAID.
April 4 and 7, 1994, Islamabad.
21. Joseph Wheeler, Chief of Mission, USAID Pakistan
(1969-1977).
Personal correspondence with author, April 4, 1994.
22. Carol Presern, Health and Population Office, Overseas
Development Administration (UK).
April 7, 1994, Islamabad.
23. John Blackton, Chief of Mission, USAID.
April 7, 1994, Islamabad.
24. Wendy Miller, Canadian International Development Agency.
April 11, 1994, Islamabad.
25. Nesim Tumkaya, Country Director, UNFPA.
April 18, 1994, Islamabad.
Appendix II. List of major political events, legislation, and
policy developments affecting Pakistan's population programme.
1947 Pakistan's independence.
1953 First volunteer work to provide women with birth con-
trol services is begun in Lahore, marking the birth of
the Family Planning Association of Pakistan.
1955 First Five Year Plan mentions importance of curbing
population growth rate to successful economic
development.
1958 Act of Parliament grants Rs.500 000 to Family Plan-
ning Association for population activities.
1959 National Family Planning Board established, to intro-
duce services. Representatives of FPAP included.
1960 Second Five Year Plan provides Rs.30 million for
clinical activities through government outlet.
Limited US aid begins through Population Council.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
21. 50 Ayesha Khan
1961 Muslim Family Laws Ordinances passed granting
women unprecedented rights, including requirement that
marriage, divorce and polygymy be registered with
Union Council. Further, women's grounds for divorce
broadened.
1965 Third Five Year Plan launches first comprehensive
Family Planning Scheme with separate administrative
infrastructure for family planning services.
War with India, family planning activities delayed and
then resumed.
1968 Agitation against Ayub Khan's government; religious
parties and Zulfiqar Ali Bhutto's People's Party attack
the population programme as part of campaign.
1969 Ayub is replaced with General Yahya Khan.
1971 Civil war, and East Pakistan becomes newly indepen-
dent Bangladesh. During and immediately after the war,
all social sector activities are brought to a standstill.
1973 Government is broke, with new President Zulfiqar Ali
Bhutto attempting to re-establish Pakistan's credibility
internationally and also maintain leftist, non-aligned
ideology at the same time.
Continuous Motivation System, derived from Sialkot
Experiment in 1968, extended nation-wide. It is client-
based and uses motivation teams for outreach.
1974-77 Contraceptive Inundation is added to CMS reflecting
USAID's conviction that flooding the market with sup-
plies will increase contraceptive prevalence.
USAID involvement at highest level yet during this
period.
Freeze on USAID April 1976-Sept 1978 due to Islamic
bomb crisis.
1977-80 Martial law under General Zia ul-Haq. For three years,
field activities of population programme brought to a
stand-still.
Population Welfare Division brought under Ministry
of Health, with Division headed by full Secretary and
employees made full government servants. The pro-
gramme is fully federalized.
1979 Hudood Ordinances promulgated, as Islamic punish-
ment for certain crimes. These include sex outside of
marriage and rape. Maximum punishment for these of-
fences is death, with conditions that place the onus of
proof of innocence upon the women. These new laws
are considered major setback for women in Pakistan.
Former Prime Minister Zulfiqar Ali Bhutto is tried and
executed.
US Embassy burned in Pakistan, political turmoil results
in USAID cut-off again, after brief 6 month resumption.
1980-83 Population Welfare is removed from Ministry of Health
and brought under Ministry of Planning and
Development.
Presidential Ordinance issued September 1, 1983 (Field
Activities Act) transferring responsibility for field
activities in the population programme to the provinces.
New multi-sectoral strategy is developed, linking family
planning with health, education, and women's develop-
ment activities. Dr Attiya Inayatullah, President of
Family Planning Association, is made Advisor to the
government on population.
CMS disbanded, and family planning staff cut from
16 000 to 8500.
USAID resumes in 1982 with a $25 million project for
population.
1983 New strategy is launched as part of Fifth Five Year
Plan. Programme de-fedcralized, with research, IEC,
social marketing of contraceptives, and funding to
NGOs as major initiatives.
1985 Dr Mahbub ul-Haq, General Zia's powerful Minister
for Finance and Planning, enters forefront of population
campaign. Ban is lifted on publicity for family planning.
NGOCC (Non-Government Organization Co-ordinating
Council) begins its function of allocating funds to local
NGOs for family planning activities.
USAID internal evaluation results in expansion of
assistance to $73.4 million for population.
1989-90 Benazir Bhutto's elected government draws up plan to
focus family planning in urban centres of Pakistan;
health services are required to offer family planning
as well.
Ministry of Population Welfare is created.
Qisas and Diyat Ordinance promulgated by President
Ghulam Ishaque Khan, upon recommendation by the
Council of Islamic Ideology. It prescribes punishments
of retribution or compensation for murder. Abortion
is included as an act of murder, in which mother and
person who performs the service are culpable.
1991 Nawaz Sharif's elected government appoints Begum
Abida Hussain, prominent politician, as Advisor on
population. Eight months of strong media publicity,
with National Population Conference held and a state-
ment by Nawaz Sharif.
Population, along with sanitation, rural development,
and female education, is designated a main focus of the
government's new Social Action Program, designed
with assistance of the World Bank to integrate and
improve social sector programmes.
Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
22. Population policy in Pakistan 51
1993
Shariah Bill is passed, a watered-down version of the
original version first discussed during General Zia's
rule. It brings legal, constitutional, and certain struc-
tural changes intended to Islamize Pakistan's social,
economic and political system.
USAID announces no forthcoming funds; Pressler
Amendment requires US government to cut-off
assistance because of Pakistan's nuclear programme.
Benazir Bhutto's newly elected government declares
population to be a top priority. It is announced that
33 000 lady health visitors will be trained to impart
family planning and basic health care at the village level.
US aid formally finishes, all funds in the pipeline dry
up. Population receives support from the World Bank
as part of its assistance to SAP, and the Asian Develop-
ment Bank also gives a loan for pan of the Eighth Plan
project.
The Eighth Plan includes, as a new initiative in the
population programme, a scheme to hire and train
12 000 village-based family planning workers for mot-
ivation and outreach.
NGOCC mandate expires, MPW and donors disagree
over its level of autonomy and its reconstitution remains
pending.
Appendix III. Budgetary allocation and expenditure on Family Planning Programme by Five-
Year Plan Period, 1955-present
Years
1955-60
1960-65
1965-70
1970-78
1978-83
1983-88
1988-93
1993-98
Allocation
(in
0.5
30.5
284
1028.8
1800
2300
3535
9000
Expenditure
million Rs.)
_
19
356
833.9
617
1686.26
3172.495
%foreign
assistance to
expenditure
_
60
18.1
51.3
18.8
52.9
38.6
Utilization
_
62.29
125
81.1
75
82
104
•This figure is a percentage of the amount actually released by the government in its Annual
Development Plans.
Sources:
Government of Pakistan (1965, 1970, 1978, 1983, 1988); Hakim (1992); Ministry of Popula-
tion Welfare (1992, 1994). Downloaded
from
https://academic.oup.com/heapol/article/11/1/30/608057
by
guest
on
04
January
2021
