Report No. 2018-PAK

Pakistan: Population Planning andSocial ServicesApril 7, 1978 FILE COPYDevelopment Economics DepartmentSouth Asia Programs Department

FOR OFFICIAL USE ONLY

Document of the World Bank

This document has a restricted distribution and may be used by recipientsonly in the performance of their official duties. Its contents may nototherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

Currency Unit = Pakistan Rupee (PRs)PRs 9.90 = US$1.00PR 1.00 = US$0.10PRs million = US$101,010

FISCAL YEAR

July 1 to June 30

FOR OFFICIAL USE ONLYPage 1 of 2 pages

COUNTRY DATA - PAKISTAN

AREA POPULATION DENSITY 2803,943 km2

73.6 million (mid-1976/77) 92 per km2,943 k. ~~~~~~~~~~~~~~~~224 per km of arable land

POPULATION CHARACTERISTICS (1973) HEALTH (1976)Crude Birth Rate (per 1,000) 47 Population per physician 4,070Crude Death Rate (per 1,000) 17 Population per hospital bed 1,720Infant Mortality (per 1,000 live births) 113

INCOME DISTRIBUTION (1970/71) DISTRIBUTION OP LAND OWNERSHIP% of national income, highest quintile 42 X owned by top 10X of owners

lovest quintile a x owned by smallest 10X of owners..

ACCESS TO PIPED WATER (1976) ACCESS TO ELECTRICITYX of population 59 2 of population - urban

- rural

NUTRITION (1974) EDUCATION (1975/76)Calorie intake as X of requirements 93 Adult literacy rate % 21Per capita protein intake 56 Primary school enrollment 2 47

GNP PER CAPITA IN 1976: US 5170-'

GROSS NATIONAL PRODUCT IN 1 9 7 6 /7 7 -/ ANNUAL RATE OF GROWTH (X. constant prices)

US S Mln. X 1960-65 1965-70 1972/73-76/77

GNP at Market Prices 15,131 100.0 6.6 6.8 4.5Gross Domestic Investment 2,741 18.1 14.7 0.6 4.5Gross National Saving 1 634 10.8 17.1 4.5 5.2Current Account Balance-3 -1,052 -7.3Exports of Goods, NFS 1,405 9.6 8.1 6.1 -1.6Imports of Goods, NPS 2,880 19.8 9.5 0.2 3.0

OUTPUT, LABOR FORCE ANDPRODUCTIVITY IN 1976/77

Value Added-/ Labor Force5/ V. A. Per WorkerUS $ Mln. 2 iMl. 2 USE

Agriculture 4,450 33.3 11.7 53.9 380 61.7Industry 2,834 21.2 2.9 13.4 835 135.6Services 6,073 45.5 7.1 32.7 855 138.8Unallocated

Total/Average 13,357 17 100.0 T10.0

GOVERNMENT FINANCE

General Government6/ Central Government(Rs Mtln.) 2 of GDP (Rs Mln.) 2 / I of GDP1976/77 2 1976/77 1970t71-74/75 1976/77 ' 1976/77 1970/71-75/76

Current Receipts 22,418 3.5.4 15.0 16,873 11.6 11.4Current Expenditures 22.846 15.7 16.2 16.231 11.1 11.9Current Surplus ,-428 -0.3 -1.2 642 0.4 -0.5Capital Expenditures-/ 14,712 10.1 7.9 11,480 7.9 5.9External Assistance (net) 6,057 4.2 4.5 6,057 4.2 4.5

1/ Based on World Bank Atlas methodology and calculated at average 1974-76 prices and exchange rates. All otherconversions to dollars in this table are at the average exchange rate prevailing during the period covered.

2/ Provisional.

3/ Inclusive of net factor service income.

4/ GDP at current factor cost.

j/ Estimated labor force as on January 1, 1975; unemployed are allocated to sector of their normal occupation."Unallocated" consists mainly of unemployed workers seeking their first job. Distribution of labor force in1974/75 is estimated on the basis of an average of Labor Force Survey results of 1970/71 and 1971/72.

6/ Consolidated revenues and expenditures of Central and Provincial Governments (excluding center-provincialGovernment transfers).

7/ Excluding principal repayments of foreign loans. Capital expenditures as defined in Government budget includecertain current expenditures also.

Not available.

Not applicable.

March 10, 1978

This document has a rstricted distribution and may be used by recipients only in the performanceof their ofkial duties. Its contents may not otherwise be disclosed without World Sank authorization.

Page 2 of 2 pages

COUNTRY DATA - PAKISTAN

MONEY, CREDIT and PRICES 1972/73 1973/74 1974/75 1975/76 1976/77-/(Million Rs outstanding end period)

Money and Quasi Money-2/ 31,497 32,658 35,669 43,142 53,066Bank Credit to Public Sector 14,099 14,297 16,928 22,110 28,327Bank Credit to Private Sector 16,259 18,378 19,983 23,407 30,298

(Percentages or Index Numbers)

Money and Quasi Money as % of GDP 47.4 37.9 32.1 33.2 36.4General Price Index (1960 = 100) 179.7 229.1 288.9 321.8 357.1Annual percentage changes in:

General Price Index 19.7 27.4 26.1 11.4 11.0Bank Credit to Public Sector 11.8 1.4 18.4 30.6 28.1Bank Credit to Private Sector 17.5 13.0 8.7 17.1 29.9

BALANCE OF PAYMENTS MERCHANDISE EXPORTS (AVERAGE 1972/73 - 1976/77)

1974/75 1975/76 19 7 6 /7 7 i/ US $ Mln %(Millions US$)

Raw Cotton 87 8.4Exports of Goods, NFS 1251 1432 1405 Cotton Yarn 143 13.9Imports of Goods, NFS 2551 2587 2880 Cotton Cloth 138 13.3Resource Gap (deficit - -) -1300 -1155 -1475 Rice 194 18.8

All other commodities 470 45.6Interest Payments -93 -109 -141 Total 1032 100.0Workers' Remittances 213 335 578Other Factor Payments (net) 12 -18 -14Net Transfers .. .. .. EXTERNAL DEBT, JUNE 30, 1977Balance on Current Account -1168 -947 -1052

US $ MlnDirect Foreign InvestmentNet MLT Borrowing Public Debt, incl. guaranteed 6,262Disbursements 956 843 817 Non-Guaranteed Private Debt ..Amortization 135 147 169 Total outstanding & Disbursed 6,262Subtotal 821 696 648

Capital Grants 63 126 144 DEBT SERVICE RATIO FOR 1976/775/Other Capital (net)3/ 201 135 44Other items n.e.i. - 176 156 18 %Increase in Reserves (+) +93 +166 -198

Public Debt, incl. guaranteed 15.6Gross Reserves (end year) 470 636 438 Non-Guaranteed Private DebtNet Reserves (end year) 4/ 56 126 -122 Total Outstanding & Disbursed 15.6

RATE OF EXCHANGE IBRD/IDA LENDING, (December, 1977) (Million US $):

Through May 11, 1972 From May 12, 1972-Feb. 15. 1973 IBRD IDAUS$ 1.00 = Rs. 4.7619 US$ 1.00 = Rs. 11.00Rs. 1.00 = US$ 0.21 Rs. 1.00 - US$ 0.09 Outstanding & Disbursed 328.4 623.1

Undisbursed 137.5 167.6Since February 16, 1973 Outstanding incl. Undisbursed 465.9 790.7US$ 1.00 = Rs. 9.90Rs. 1.00 = US$ 0.10

I/ Provisional.

2/ Monetary statistics of Pakistan have been fully adjusted for demonetized notes, devaluation and revaluationof the rupee, etc., as from June 30, 1975. Data for 1974/75, from State Bank resources are not strictlycomparable with IMF estimates for earlier years.

3/ Including errors and omissions.

4/ Net of net IMF position.

5/ Ratio of actual debt service to exports of goods, non-factor services and workers' remittances.

Not available.

Not applicable.

IBRD 13576620 66° 700 740 APRIL 1978

-360 PAKISTAN U S. S. R. HPRIMARY ROADS -36°-

SECONDARY ROADS - -

-I---- RAILWAYS .'N

4. AIRPORTS

PROVINCE BOUNDARIES - - j JAMMU- INTERNATIONAL BOUNDARIES ) AND

RIVERS q (-'pprox-*j;.*Cli°Peshawar -

c >' *.- K;SHMIR0 100 200 300 400 ROwalpindi

K ILOMETERS

Khus b pel~ ~ Apro~rat

D. 1 Kola \.C- / olp-r .e f N D I A

INDIASCHINA

Kola S NwoBHUTANt \ JacoeaboA Sea

IRAN / J --) / / /22+S~~~~~~~~uurk/ N U. R,4f Prxme

L rne o Control

620. 66~~~~~~~~~~~~~~~ 700 ~ ~ ~ ~c BeINgAl

/ Bela \ S I N D__ ,__,_._7r_BUTA

. : Buleji PLderobQd . <, ~~~~~~~~~~I N D I A . , ' . ' ~~~~KARACHI t Ttta . 4 . . g 1 Z fJt, . . 3 1 9-~~~~~B LADESH

-24° Arabian Sea 240 . 4p ._--/-A arbian7 Sea Iis . .: . :/ , \ < . ~~~~~~~~~~~~~~~~~~~~Bay

62° 1., ,Whs 7° ' ? 70°0;> t .

I

PAKISTAN

POPULATION PLANNING AND SOCIAL SERVICES

Table of Contents

Page No.

COUNTRY DATA AND MAP

I. INTRODUCTION, SUMMARY AND CONCLUSIONS .... ............ 1

II. DEMOGRAPHIC TRENDS AND PROSPECTS ..................... 10Past Trends and Present Situation .... ........... 11Mortality ..................................... 11Fertility ..................................... 11Structure of the Population .... ............... 13The Supply of Labor ........................... 14

The Future - Population Projections .... ......... 15Overall Effects ............................... 16Impact on Education ........................... 17Employment .................................... 18Income ........................................ 19

III. POPULATION PLANNING .................................. 20Socio-Economic Conditions and Fertility .... ..... 20The Family Planning Program ..................... 22

Delivery Systems .............................. 23Program Performance ........................... 24

The Draft Plan for Population Planning .... ...... 26Motivation .................................... 26Service Delivery .............................. 26Service Integration ........................... 27Organization .................................. 27Logistical Support ............................ 27The Prospects for Program Success .... ......... 28The Market for Family Planning .... ............ 28Resource Availability ......................... 28Can the New Plan Reach the Market? .... ........ 29

IV. .THE HEALTH SYSTEM .... . ................................ 30The Health Situation ............................ 30Mortality and Morbidity ....................... 30

The Causes of Poor Health ....................... 31The Nutrition Problem ......................... 32Water Supply and Waste Disposal .... ........... 34High Fertility ................................ 34

Table of Contents (Continued)

Page No.

The Health System in Pakistan ..... ............. 36

Public Health ....... ......................... 36

Social Security ....... ....................... 38

The Private Sector ...... ..................... 39

Improving Public Health ........................ 40

V. THE EDUCATION SECTOR ................................ 45

Background, Structure and Objectives .... ....... 45

Background ................................... 45

Structure .................................... 45

Objectives ................................... 49

Efficiency of Educational Investment .... ....... 49

Primary Schooling ...... ...................... 50

Technical Education and Training .... ......... 52

Higher Education ...... ....................... 52

Women in Education ...... ..................... 55

Curriculum Reform ...... ...................... 57

Examinations ........ ......................... 58

Economic Impact of Educational Investment ...... 59

Unemployment of the Educated ..... ............ 60The Brain Drain ....... ....................... 62Economic Growth and Income Distribution ...... 65

Conclusions ......... ........................... 67

APPENDIX 1: DERIVATION OF THE POPULATION PROJECTIONS .... 69-77

REFERENCES .......... ..................................... 80-90

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List of Tables

Table Page No.

1 Population Growth - 1901-77 ............................ 10

2 Average Annual Vital Rates ............................. 12

3 Total Population, Population 10 Years of Age and Over,Population in Age Group 15-64, and Civilian LaborForce ............. ................................... 15

4 Total Population for Specified Years Under DifferentFertility Assumptions, 1977-2017 ..... ................ 16

5 Population of School Age for Given Years Under FourProjections of Population ............................ 18

6 Distribution of Countries According to Birth Rates andInfant Mortality Rates ............................... 22

7 Estimated Deaths by Cause .............................. 32

8 Daily Per Capita Consumption of Calories, Proteinsand Fats for 1959/60, 1964/65 and 1969/70 .... ........ 33

9 Measures of Health Status by Level of Per CapitaGross National Product (GNP) in Selected Countries ... 36

10 Benchmarks and Physical Targets for the Third andFourth Five Year Plans in the Health Sector .... ...... 37

11 Total Number of Employees Insured Under Social Security,1970-75 ........... ................................... 38

12 Estimated Annual Expenditure on Medical Treatment inPrivate Sector, 1974 ................................. 40

13 Proposed Health Structure .............................. 42

14 Projected Expansion of Human and Physical Resources forHealth Under the Fifth Plan .......................... 44

15 Growth in Enrollments, Schools and Teachers Between1965/66 and 1975/76 .................................. 47

16 Percentage of 5-9 and 10-14 Age Groups Enrolled in School 48

17 Education Expenditure as a Percentage of the GNP forSelected Countries .48

- iv -

List of Tables

Table Page No.

18 Expansion of Higher Education ........................ 53

19 Labor Force and Unemployment According to Level ofEducation .......... ................................ 61

20 Stock of Surplus Educated Manpower (Matric and Above),1965-90 ........... ................................. 62

21 Workers' Remittances (1971-76) and Number of EmigrantsSelected by the Bureau of Emigration and OverseasEmployment ......... ................................ 63

22 Costs of Education According to Level .... ............ 64

23 Total Government to Educate Professionals .... ........ 65

Fig 1 Percentage Female Enrollment in Primary and SecondarySchools .56

APPENDIX 1

A-1 Population Distribution According to the HED Survey 70

A-2 Base Population (July 1, 1972) used for the PopulationProjections 72

A-3 Base Year Age-Specific Fertility Rates 74

A-4 Total Fertility Rates Used in Projections 75

A-5 Rural-Urban Transition Figures 76'

A-6 Age Distribution of Rural Population Becoming Urban 76

A-7 Labor Force Participation Rates Utilized for Projections 77

A-8 Pakistan Population Projections (1977-2017) by SelectedSocio-Economic Groups 78

A-9 Pakistan Population Projections (1977-2017): Vital Rates 79

PAKISTAN

POPULATION PLANNING AND SOCIAL SERVICES

I. INTRODUCTION, SUMMARY AND CONCLUSIONS

1.01 During the 30-year period since Independence the standard of livingin Pakistan has improved relatively slowly, especially for those in the lowincome groups. Average per capita income is now about $170 per annum comparedwith about $105 in 1947; income distribution has probably changed little; andbasic social services have generally not reached the poor. This situation isdue in part to rapid population growth, which has impeded growth in per capitaincomes without contributing to increased production, has affected income dis-tribution by providing an excess supply of labor relative to the jobs avail-able, and has made the task of the Government in providing social servicesmore difficult. Efforts at reducing fertility and consequently the rate ofgrowth of population have been hampered by the country's overall poor socio-economic situation, a factor which has been shown to correlate negatively withfertility reduction.

1.02 The Government has put considerable effort into attempts at provi-sion of health and education services and reduction of the rate of populationgrowth but has met with only limited success. The present report attempts toindicate why this has happened and what the lessons are that must be learnedif greater success is to be achieved in the future. The report identifiesweaknesses in the provision of services and provides recommendations for theimprovement of the different programs. It also attempts to demonstrate howfactors related to population planning, health and education interact in sucha way that failure to improve the situation in one of these sectors makes itdifficult to improve the situation in the others.

Demographic Trends and Prospects

1.03 At the time of Independence, Pakistan had approximately 32 millionpeople. By mid-1977 the population approached 80 million. This increasereflects an average rate of growth of 3.1% per year. In 1947 the crude deathrate was probably about 25 deaths per thousand population; at present, thecrude death rate is about 13, representing a decline of 50%. This decline,a continuation of a process begun early in the 20th century, has been duemainly to increased availability of food and the control of epidemics such

This report is the result of the research and visits to Pakistan ofa human resources mission led by Mr. Roberto Cuca (Population), and includingDr. Lawrence Casazza (Health), Mr. John Simmons (Education), and Mr. AlbertBerry (Income Distribution and Employment, Consultant). Mr. Philip Brockassisted throughout the research and preparation of the report.

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as plague, smallpox and cholera as a consequence of immunization and sur-veillance. At present, there are still important differences in mortalityrates between various groups. Mortality among the rural population is higherthan in urban areas. Mortality of females is at least equal to that of males,although it is lower in most countries. The groups most affected are infantsand mothers.

1.04 Fertility rates, on the other hand, have not changed significantlyduring the present century. The crude birth rate for the country is stillwell over 40 births per thousand population. As with mortality figures,there are differences in fertility among different groups of the population.The evidence indicates that fertility is inversely related to education ofwomen; that rural women have higher fertility than urban women; and thatfertility is higher among those women whose children have suffered highmortality. These differences, which have been observed in many countries,suggest that a more modern environment, with improved health conditions,and better education of women lead to lower fertility.

1.05 Fertility rates are closely related to the level of socio-economicdevelopment. In poor societies, families tend to have a larger desired andactual family size than in rich societies. One reason often given for thisis that poor families need to have more children to guarantee security duringparental old age. In a country like Pakistan, where income is low, wherewomen are accorded low status and do not participate in economically produc-tive activities, and where infant mortality is high, insurance for old agemeans having a high number of sons and, therefore, high fertility. Surveydata for Pakistan indicate that couples with low incomes, whose childrensuffer high mortality and who do not initially have many sons, tend to havethe highest fertility.

1.06 The rapid decline in mortality without a corresponding decline infertility explains the rapid increase in the rate of growth of the populationsince Independence. Rapid growth is increasing the proportion of the populationliving in urban areas (26% as of 1972), but Pakistan remains predominantly arural society. Another result of the rapid growth is that Pakistan's popula-tion is relatively young. In 1972 approximately 45% of the population wasless than 15 years of age; 5% was over 65. This age structure, plus the lowparticipation of women in economically productive activities, has produced avery high dependency ratio for workers. The labor force in 1972 numberedabout 20 million people, an increase between 1951 and 1972 of 10.4 million.This was due mainly to population growth, although it reflected also asmall increase in participation rates. During that period, the proportionof women in the labor force increased from 3.1% to 8.8%.

1.07 Given past population growth trends and assuming some gains insocio-economic development and a moderately effective family planning program,the population is likely to increase at an average annual rate of 3.2% overthe next 40 years, reaching 286 million by the year 2017. If it is assumedthat present Government objectives for the population planning program are

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achieved, the population would grow at an average annual rate of 1.7% duringthe next 40 years and reach only 159 million in 2017. To achieve this,however, the Government would need to mount a very strong program of fertilitycontrol which, in addition to providing family planning services, would haveto include social development measures in health, education and women'semployment opportunities.

Population Planning

1.08 The interest of the Government in population planning dates back tothe mid-1950s. Although minor at first, Government participation has grownto include, at present, most types of family planning activities. The familyplanning services provided, however, have not significantly affected fertility.The lack of progress is explained both by the socio-economic conditions inPakistan, which are not yet propitous to a high demand for contraception, andby a delivery system which has not provided the quantity and quality of ser-vices required to meet even the existing demand.

1.09 Responsibility for policy-making, financing and implementationof the population program has changed several times. The methods used todeliver services have also changed. Services were provided initially byclinical staff on a limited basis. Traditional midwives were subsequentlyutilized, but emphasis on clinical methods was retained. Since 1973 serviceshave been provided by male-female teams who make house-to-house visits tomotivate and deliver contraceptives. This system was called the ContinuousMotivation System (CMS) because workers were expected to visit each householdfour times a year. In 1975, the Inundation System was added to the programwith the purpose of ensuring wide availability of contraceptives (pills andcondoms) throughout the country.

1.10 None of these efforts has succeeded in reducing the fertility rate.Current estimates indicate that only about 6% of married women of childbearingage practice contraception on a continuous basis. These poor results are dueto organizational problems, lack of appropriate training and supervision, andinadequate communications and research.

1.11 The Government has recognized the failure of past programs and anew strategy for population planning is under consideration. Experience in-dicates that a successful program will require greater efforts in motivationthrough the use of paramedical staff, mass media and influential village women;changes in service delivery, with improvements in clinical services, moreeffective means of contraception, and a better system of commercial distribu-tion of contraceptive supplies; and greater integration of family planningwith health services and with development efforts of other ministries.

1.12 The prospects for success of any new program will depend on theavailability of adequate resources and the existence of the necessary insti-tutional framework for its implementation, and strong Government. commitmentto the program. Although the poor past results have inevitably made both theGovernment and foreign donors reluctant to provide finance for populationplanning, no program can succeed without sufficient funds.

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1.13 Socio-economic conditions usually associated with positive attitudestoward family planning are slowly improving in Pakistan. According to thePakistan Fertility Survey, 17.4% of currently married women do not want tohave more children, are not actually practicing contraception but are notopposed to the idea. If this group of women alone could be reached and moti-vated to practice contraception effectively, the birth rate could be reducedto about 37 per thousand population.

The Health System

1.14 Pakistan faces today, to a lesser degree, the same health riskswhich prevailed at the time of Independence. These include widespread, butpreventable, communicable diseases; moderate to severe malnutrition amongchildren and women of childbearing age; inadequate or absent facilities forwaste disposal and clean water supply; and high fertility rates with their con-comitant risks for mothers and their offspring. This situation is worse forthe rural than for the urban population. Leading causes of death are commonrespiratory infections, diarrhea, congenital abnormalities-, tuberculosis,malaria and typhoid fever. The last 30 years have seen considerable improve-ments in health as evidenced by the reduction in mortality. These changeshave resulted from economic and social modifications, together with measuresspecifically aimed at disease prevention and health care.

1.15 Nutrition interacts with infection in two ways: (a) malnourishedpersons are more susceptible to infections; and (b) infections can precipitatemalnutrition. Summary results of the 1969 National Nutrition Survey indicatethat about 46% of families have inadequate calorie intake; of them, 11% con-sumed less than 70% of recommended allowances. Food balance sheets for 1969-70showed that per capita daily protein intake is only 48 grams, as opposed tothe recommended 62.5 grams.

1.16 Environmental sanitation remains a serious problem in Pakistan andexplains in part the very high incidence of parasitic infections, cholera,typhoid fever and non-specific gastroenteritis. Less than 60% of the popu-lation has access to potable water and only about 15% has access to basicsewerage facilities. However, better supply of water and sewerage facilitiesalone will not be sufficient to improve health unless educational campaignsaccompany the provision of these services so that the population learns howto use them.

1.17 High fertility rates affect the mortality of both mothers andchildren. High maternal mortality is due to the complications of pregnancyand childbirth, but it also increases with the age of the mother and thenumber of pregnancies. A high proportion of deaths is due to abortion compli-cations. Abortion, not being legal, is usually performed in less than optimumconditions. The'ratio of stillbirths and infant mortality also increases withthe age of the mother.

1.18 Health services originated in Pakistan many centuries ago, as isevidenced by the continued popularity of the hakims and vedic practitioners.The British brought western medicine, establishing hospitals and dispensariesthrough the local governments. The first national health program, the "People's

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Health Scheme," was introduced only in 1972, although emphasis had been givento preventive and curative health services in the Second Five Year Plan(1960-1965). Successive plans established objectives in terms of health,manpower and physical facilities. In general the plans fell short of thetargets both in terms of manpower and needed infrastructure. The main reasonfor this was the lack of financial resources. The cornerstone of the planproposed in the People's Health Scheme was a Basic Health Unit (BHU), to servebetween 6,000 and 15,000 people as a sub-unit of a larger Rural Health Center(RHC). BHUs and RHCs were then to refer the more seriously ill to "tehsil"hospitals of 60 beds or district hospitals of 250 beds. Implementation ofthis system is still limited.

1.19 Another source of health care in Pakistan is the Social SecurityProgram. In 1967, the Government introduced a pension scheme for indivi-dual workers which provides medical care to the workers and their dependents.At present, there are three semi-autonomous employee social security insti-tutions--one in each of three provinces--covering workers earning less thanRs 1,000 per month. Employees do not contribute to this system; employerscontribute 7-8% of wages. The number of employees covered in 1974/75 wasabout 400,000 or, with dependents, the equivalent of 2.6 million people.Most of the system's medical facilities are in urban areas, and those out-side urban centers are usually under-staffed.

1.20 Private sector medical care includes doctors practicing westernmedicine and an estimated 40,000 indigenous health practitioners. Approxi-mately 10% of the latter are physicians or Hakims trained in the Unani MedicalSystem. Most indigenous practitioners are located in rural areas where theyconstitute the major source of health care. There is also a large number ofchemists in Pakistan who provide all types of medicines, including the latestAmerican and European drug products. The provision of drugs by chemists hasproduced drug resistant strains of some organisms because of inadequate dosage.Expenditure in the private sector is impossible to assess with any accuracy.The Planning Commission estimates a total of Rs 1.5 billion for 1974. Thisis more than four times the amount spent in the public sector and would implyexpenditures on health of about 2.4% of GDP.

1.21 Until now the type of health services provided by the Government hasreflected the established priorities usually set by hospitals and medical andnursing schools. Funds earmarked for preventive measures have been meager incomparison to curative costs; the bulk of the national preventive health budgetgoes for malaria control alone. The draft Fifth Plan envisaged a substantialshift from the present doctor-oriented strategy for delivery of health servicesto one employing auxiliaries and community health workers. It also aimed toshift the emphasis of these services from curative to preventive measures.The rural areas were designated as the priority regions to receive these newworkers and services. Support for environmental sanitation was to be greatlystrengthened. The program implied extensive manpower training, new construc-tion and an expanded logistics system, with large implications for recurrentcosts. It was expected that, by 1983, 65% of the total population would becovered by this system. This would be a major increase from the 20% currentlycovered.

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1.22 The proposed program raised four major issues: first, the capabil-ity of the Federal Government to effectively plan and direct provincial healthprograms; second, the country's capacity to develop an extensive rural healthprogram with well defined criteria to identify those most at risk; third, theGovernment's ability to integrate the present vertical health programs includ-ing family planning into a health system which cooperates with the indigenoussystem and other health service resources; and fourth, and perhaps the mostimportant, the Government's capability to establish a solid community organi-zation base to ensure local participation in and support for the health careprogram.

1.23 Opposition to the proposed approach could be expected from somepeople in the medical profession and from the middle and upper classes, whichhave benefited from the services provided by sophisticated medical facilitiescatering to a small minority in the urban areas. The Government could alsobe opposed by the poor if it attempted to extract payment for health services,unless it shared with them the responsibility for decision-making and adminis-tration of those services. In the past, a variety of pressures have preventedmeaningful changes to the health system. Social services have also been amongthe first to suffer from budgetary cuts.

The Education Sector

1.24 Educational opportunity has expanded rapidly over the 30 yearssince Independence. In 1947 there was a total at all levels of one millionstudents; today that figure is seven million. Only about 11% of primaryschool age children were in school in 1947; by 1976 the number had grownto 44.2%. This does not imply that the problems have been solved. In 1947,4.7 million children were not in school; today that number has reached 7.0million. Currently, only about 16% of all girls aged 6-14 are enrolled inschool, compared with 46% of boys. Parents find that education is not econo-mically beneficial for their children. The quality of education leavesmuch to be desired, partly as a result of poor teacher supervision due tolack of local accountability.

1.25 Pakistan compares unfavorably with other Asian countries in termsof the proportion of GNP going to education. This is especially true whenone looks at resources allocated to the lower grades, reflecting the biasin favor of higher education. The education system does not appear to becontributing efficiently either to economic growth or equity. It is not serv-ing the economy well because it is not producing the types of skills requiredby employers. There is a great deal of unemployment among the educated, oftenof long duration. A major reason for this has been the very rapid expansionof higher education.

1.26 Secondary and higher education are now expanding faster than primaryeducation. This trend must be reversed to achieve the Government's objectiveof universal primary education, but this will not be easy in view of the in-creasing demands for school places beyond the primary level. A significantincrease in the number of primary schools may also not be possible unless

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innovative approaches to school construction are tried. Reduction of the highpercentage of dropout rates will require that primary education is made moreinteresting and relevant to the lives of the students.

1.27 Major improvements are similarly necessary in the planning andconduct of technical education. Some colleges and institutes have now estab-lished advisory councils made up of representatives of management and labor.If these councils have a real voice in training activities, they will be ablenot only to indicate the need for particular types and numbers of workers butalso to influence the quality of training and help ensure placement in appro-priate jobs once training is completed.

1.28 Colleges and universities absorb 40% of the capital expenditures oneducation. Yet they appear to comprise the level of education least responsiveto national development needs. The objective of the draft Fifth Plan was toslow the rate of growth of higher education while improving its quality. ThePlan called for a reduction in the share of both capital and recurrent ex-penditures for higher education. The evidence indicates that at present thereis a very low utilization of capacity in higher education and that academicstandards have fallen.

1.29 Education and better employment opportunities for women are factorswhich can be correlated with lower fertility and better family health. A Gov-ernment objective is to provide equal access to education for women throughprovision of special facilities. Female enrollments as a percentage of totalenrollments have increased at all levels since Independence. Women, however,drop out of school faster than men, possibly because female education is seenas wasted given the lack of employment opportunities. Thus, increased pos-sibilities of employment for women may be a necessary concomitant of increasededucational opportunities.

1.30 Another objective of the Government is to make education more prac-tical and meaningful. At the secondary level this is to be achieved throughrapid introduction of agrotechnical courses. At higher levels the goal is toshift enrollment from arts to science and technical subjects. Thought needsto be given, however, to the methods by which these shifts might best beaccomplished. In addition, further evaluation of this approach in terms ofexpected results is needed. Based on the experience of other countries, thesuccess of such programs is linked to an increase in the responsibility ofparents and leaders in planning and managing school activities. This is beingcurrently considered in some provinces and universities in Pakistan.

1.31 The examination system is in need of reform. Examinations havebecome more important than learning itself. Internal evaluations are givenlittle importance and external examinations can be passed by rote. Studieshave shown that performance in exams at a given level of schooling is not agood predictor of future performance at a higher level. Several educationcommissions have recommended the institution of internal evaluations togetherwith the maintenance of cumulative records to evaluate student achievement.

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1.32 Pakistan is suffering the effects of a brain drain. Two types oflabor are emigrating with different effects. The first group, made up ofprofessionals, go in general to developed countries, usually take theirdependents with them, and thus do not normally send remittances home. Theireducation is very costly but the country does not realize the benefits of thateducation either in services or financially. In the second group are skilledand semiskilled workers who go in the main to the Middle Eastern countries fora fixed period of time--one or two years--leave their dependents behind andsend a great deal of money home in remittances. The cost of their educationis low and paid mainly with private funds. On their return, they are likelyto have added skills and can, therefore, be more productive.

1.33 Expansion of free education has been seen by some observers as aneffective way to narrow the gap in income between the poorest and the richest20% of the country's population. But in practice the poor do not have anequal chance at either starting school or obtaining certificates. Most ofthe university students come from families in the high socio-economic levelwho comprise a very small proportion of the population. By subsidizing highereducation, the Government is in reality subsidizing rich students. This istrue even in the case of the President's scholarships, designed to helpstudents from poor families. To receive one of these scholarships, it isnecessary to be a first division matriculate, but there are so few poorstudents in this category that the scholarships have been awarded to studentswhose parents' income was above the envisaged ceiling. In sum, while theGovernment's goal-is to use education to promote equity, the reverse appearsto be happening.

Conclusions

1.34 Perhaps the most important conclusion of this report is that.Pakistan, despite the objectives expressed in past development plans, hasbeen unable to provide basic social services to the mass of the population.The evidence indicates that water supply, sewerage facilities, nutritionprograms, health services, and educational facilities for primary school agechildren have generally not reached the poorest 40% of the population. Theservices provided have mainly benefitted higher socio-economic groups livi.ngin urban areas. The main part of the budget for health has gone to thetraining of doctors and to hospital facilities which do not serve the poor.The largest portion of the education budget maintains university education, towhich only children from medium to high socio-economic households have access.The latter has occurred despite high unemployment of higher education graduatesand the permanent emigration of many of those graduates to other countries.

1.35 Provision of social services has increased the gap between the richand the poor. Because the status of the lower socio-economic groups has notchanged, Government policies have also made more difficult the creation ofan environment receptive to lower fertility. The consequence is that effortsin the direction of providing family planning services--which should benefitmainly the poor-have failed. This failure is aggravating the population prob-lem, thus making it more difficult in the future for the Government to providebasic services to the increasing number of poor. In the final analysis, the

main reason that the poor have not been reached with past programs hasbeen the lack of firm commitment on the part of the Government to implementproposed plans and the weaknesses of the administration to confront pressuregroups who opposed implementation.

1.36 The draft Fifth Plan set out very ambitious objectives in health,education and population planning. It promised a change in priorities andan increase in the proportions of the budget benefitting the poor throughsocial services. More importantly, it proposed innovative and low cost solu-tions, abandoning the traditional developed country orientation and acceptingthe possibility of equally effective but less sophisticated solutions to theproblems.

1.37 There are basic factors that must be taken into consideration ifresults are to be positive. The relationship between the provincial govern-ments and the Federal Government is of particular importance. It is essentialthat the objectives and activities of the provinces and the Central Governmentbe better coordinated than in the past.

1.38 Another important element is the need for community participation.Participation is needed not just to help finance capital and recurrentexpenditures but, more importantly, to make programs more responsive to localneeds. Communities should have at least a degree of participation in policyformulation and programming, as well as in direction and control of programs.Experiments in Pakistan and in other countries indicate that, when the com-munity is given responsibility for its own programs, those programs tend tobe more relevant and effective in terms of the needs of the community.Throughout the country at present there is an absence of community organi-zation.

1.39 Providing social services for the poor is not an easy task, but itcan be accomplished with strong commitment and direction on the part of theGovernment, more coordination between central and local governments, and theparticipation of the population. Improving levels of living is necessary notonly for the betterment of the welfare of the existing population but also asthe basis for attitudinal changes toward fertility, resulting in a lower levelof population growth which would eventually make the objectives of developmenteasier to reach.

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II. DEMOGRAPHIC TRENDS AND PROSPECTS

2.01 The demographic development of Pakistan has not been unlike that ofother developing countries during the present century; i.e., an accelerationin the rate of growth due to a fast decline in mortality without a correspond-ing decline in fertility (see Table 1). The acceleration in the rate ofpopulation growth has altered the age distribution and helped intensify themovement of people from rural to urban areas. It has also produced changesin the structure of the labor force which is likely to have implications foremployment opportunities and income distribution. The prospects for futuredemographic growth in the country will depend on the speed with which fer-tility can be brought under control. Mortality, especially at very youngages, can be reduced still further, but the effect of such reduction on thegeneral death rate will not be very significant.

Table 1: POPULATION GROWTH - 1901-1977

Intercensal RateCensus Year Population (000) of Growth (%)

1901 16,576 /a -1911 19,382 1.61921 21,109 0.81931 23,542 1.11941 28,282 1.81951 33,780 /b 1.81961 46,200 7 3.11972 69,253 7d 3.51977 79,753 /e 3.1

/a Excluding population of frontier regions./b Includes adjustment of 5% for undernumeration./c Corrected estimates by Haq (1974), Backett and Akers (1965)

and Pakistan Technical Sub-Committee (1968)./d Census results inflated to reflect 6.3% undernumeration./e Projected assuming an average annual rate of growth of

3.1%.

Sources: Mohammad Afzal, The Population of Pakistan.Pakistan Institute of Development Economics,1974., p. 2.

Korol J. Krotki, "Pakistan's Population Size andGrowth in the Light of the 1972 Census EvaluationSurvey." The Pakistan Development Review, Vol. XV,No. 2, Summer 1976, p. 183.

Government of Pakistan, Ministry of Finance,Planning and Development Statistical Division.Census Evaluation Survey: Population Census 1972,p. 14.

Past Trends and Present Situation

2.02 The crude death rate in British India in 1901-1910 was approxi-mately 42.6 deaths per thousand population and life expectancy at birth was23 years. 1/ Today in Pakistan, the crude death rate is about 13 and theexpectation of life at birth approximately 57 years. Except for a few yearsafter the first World War when mortality went up because of the influenzaepld6mid-, the decline in the deatY'-fat-eF'h-s--e-n approximately uniform throughthe century. The decline of 70% in the death rate has been due to two majorfactors and their synergistic effect. The first factor was increased avail-ability of food as a result of improved transport and expanded irrigation.The second factor was the control of epidemics such as plague, smallpox andcholera through immunization and surveillance. Increased food availabilitycontributed also to the control of epidemics by strengthening resistance todisease.

Mortality. Mortality differentials in Pakistan reflect the socio-economicconditions of the population. Rural areas, where poverty is greater, environ-mental conditions poor and health services practically non-existent, exhibitlower expectation of life at birth (52.2) than the urban areas (54.1), wheresocio-economic conditions are somewhat better. 2/ Women, whose status insociety is very low, exhibit higher mortality than males: expectation oflife at birth for females is 51.8 and for males 52.9. 3/ This differenceis not common to many countries. Infant mortality is still very high (about130) 4/ due to the lack of adequate maternal and child health services andpossibly malnutrition. Deaths of children under one year account for approxi-mately 38% of all deaths each year. Further reductions in the mortality ofthe least privileged groups can only be achieved by Government policiesdesigned to improve the environment, raise the status of women and broadenaccess to health services, especially for mothers and children. This willrequire both a reappraisal of priorities and a reorganization of services totake advantage of underutilized community resources and to provide communitieswith greater responsibility for their own development.

Fertility. The evidence available indicates that no major change inthe level of fertility has taken place in Pakistan during the present

1/ Kingsley Davis, The Population of India and Pakistan. Princeton,New Jersey, Princeton University Press, 1951, p. 85.

2/ Naseem Iqbal Farooqui and Iqbal Alam, "Provisional Abridged LifeTables for Urban and Rural Areas in Pakistan, Based on PGS 1968and 1971.". The Pakistan Development Review, Vol. XIII, No. 3, Autumn1974, pp. 335-352. The figures given here are for the period 1968-1971 and are possibly underestimates due to the data base used.

3/ Ibid. Again, these figures are for 1968-1971.

4/ Government of Pakistan, Ministry of Finance, Planning and Development,Statistical Division. Population Growth Survey, 1971, Karachi, 1974p. XIV.

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century. The crude birth rate is still above 40 births per thousand popula-tion, and the total fertility rate is close to eight children per woman.Table 2 indicates the basic stability of the fertility level and contraststhis with the dramatic changes in mortality.

Table 2: AVERAGE ANNUAL VITAL RATES

Births Deaths Natural(per 1000) (per 1000) Growth (%)

British India Ia

1901-1910 49.2 42.6 0.661911-1920 48.1 47.2 0.091921-1930 46.4 36.3 1.011931-1940 45.2 31.2 1.40

Pakistan

PGE (1962-1965) LR /b 42.0 15.0 2.70CS 38.0 11.0 2.70CD 52.0 18.0 3.40

NIS (1968-1969) /c 39.0 - -PGS (1968-1971) 7W 37.0 11.0 2.60PFS (1975) /e 40.5 -Bank Projections (1976) 44.7 13.0 3.17

Sources: /a Kingsley Davis, The Population of India and Pakistan.Princeton, New Jersey, Princeton University Press, 1951,p. 85.

/b M. Naseem Iqbal Farooqui and Ghazi Mumtaz Farooq (Eds).Final Report of the Population Growth Estimate Experiment,1962-1965. Pakistan Institute of Development Economics,Dacca, 1971.

/c Training Research and Evaluation Center (TREC), NationalImpact Survey Report, TREC, n.d.

/d Government of Pakistan, Ministry of Finance, Planning andDevelopment, Statistical Division. Population GrowthSurvey: 1971. Karachi, 1974.

/e Population Planning Council of Pakistan, World FertilitySurvey: Pakistan Fertility Survey, First Report, 1976.

2.03 It should not be inferred from the constancy in the generallevel of fertility that there are no fertility differentials amongdifferent groups of the population. The Population Growth Survey for1971 found that the total fertility rate for rural .women was 11% higher

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than for urban women-6.64 against 5.76. 1/ The 1972 Census and the PakistanFertility Survey showed the number of children born to illiterate women tobe higher than to those women who had completed high school. Both of thesesources also indicate that the more children a woman has had, the lower theproportion surviving, independent of the age of the woman. These differen-tials have been observed in many other countries and indicate that there isa correlation between lower fertility and a more modern environment, betterhealth, and better education of women. Better education can affect fertilityby delaying marriage and by exposing women to modernizing influences as wellas by offering them alternative ways to use their time, therefore increasingthe opportunity costs of time spent on raising children. Lower infant andchild mortality tends to reduce fertility both by increasing the period ofpostpartum amenorrhea caused by extended breastfeeding and by reducing thenumber of births necessary to achieve a given desired family size. Theseare a few of the issues which underscore areas where Government efforts canbe effective in increasing welfare for the population and possibly loweringfertility.

2.04 Structure of the Population. After 30 years of economic develop-ment, Pakistan remains predominantly a rural society. The 1972 Census found26% of the people living in urban areas, compared with 18% in 1951. As aresult of rural-urban migration, the urban population increased at an annualrate of 4.7% between 1951 and 1972. This rate probably would have been morerapid had it not been for significant agricultural developments during the1960s. These increased farmer productivity, income and the demand for labor,making it possible to sustain a larger population in the rural areas and thusdecreasing the pushing force toward the cities. Even though the proportion ofpeople in urban areas has increased, the absolute number of rural residentshas also increased. There are approximately 27 million more people living inrural areas now (1977) than at the time of Independence. The major flowsof migration have been toward the larger cities of Karachi, Lahore andFaisalabad. During the 1950s Karachi was the principal attractor of migrantsfrom the rural areas of Punjab and North West Frontier Province, but thisflow changed during the 1960s with the development of Lahore and Faisalabadas important employment centers in Punjab. Present migration patternsindicate that the poorer and less urban provinces, namely Baluchistan andNWFP, are losing population to the more urban provinces of Punjab and Sind.

2.05 Pakistan's population is relatively young. In 1972, the Censusfound that 56% of the people were under 20 years of age, and 45% under theage of 15. The high percentage under 15 reflects past improvements in healthand nutrition, which have lowered mortality, and continued high fertilitypatterns over the last 15-20 years. Few women presently participate in thelabor force, although the number has been increasing gradually. The large

1/ The importance of these figures rests on the differential betweenrural and urban rather than on the absolute level, which is under-estimated when compared with other sources.

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number of children and women outside the labor force results in a high depen-dency ratio for those men and women who do work. The average worker supportshimself or herself plus 2.5 dependents, a relatively high ratio by worldstandards.

2.06 The Supply of Labor. According to census data (see Table 3) thenumber of people in the labor force increased from 9.5 million in 1951 to12.8 million in 1961, an average annual rate of growth of 3.0%. Between1961 and 1972, the rate of growth accelerated to about 3.8% per annum,increasing the labor force to approximately 19.9 million. 1/ The totalincrease between 1951 and 1972 was 10.4 million. 79% of the increase wasdue to population growth, 11% to increased participation and the other 10%was due to the joint effect of both population growth and higher participa-tion rates. In 1951, women constituted only 3.1% of the labor force, butby 1972 that proportion had risen to 8.8% due essentially to an increasedparticipation rate.

2.07 The 1972 Census shows an unemployment rate of 12.8%, which issurprising when compared with the results of earlier censuses or with thelabor surveys where unemployment appeared to be only about 2%. 2/ Partof the problem may be definitional. The 1972 Census shows a much higherparticipation rate than the earlier studies for both males and females inthe age group 10-14. The same census shows a very higher unemploymentrate for that age group.

1/ There are serious questions about the results of the censuses. Table 4presents total population figures as well as labor force figures tofacilitate comparison without reference to corrected census figuresused in other tables.

2/ No proper evaluation has yet been made of the Housing, Economic andDemographic Survey (part of the 1972 Census) but there are seriousquestions concerning the results.

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Table 3: TOTAL POPULATION /a, POPULATION 10 YEARS OF AGEAND OVER, POPULATION IN AGE GROUP 15-64, AND

CIVILIAN LABOR FORCE(in thousands)

1951 /b 1961 /c 1972 /d

Population 31,061 39,442 60,510Population 10 years of age and over 22,712 26,513 42,379Population aged (15-64) 16,406 20,822 31,686Civilian Labor Force 9,506 12,763 19,893

Males

Population 16,733 21,168 32,511Population 10 years of age and over 12,396 14,412 23,210Population aged (15-64) 9,041 11,237 17,118Civilian Labor Force 9,213 11,641 18,152

Females

Population 14,327 18,274 27,998Population 10 years of age and over 9,316 12,101 19,169Population aged (15-64) 7,365 9,594 14,568Civilian Labor Force 293 1,122 1,741

/a Figures not corrected for undernumeration.

/b Excludes population of Frontier Regions and non-Pakistanis.

/c Excluding Frontier Regions.

/d Population according to HED Survey which excludes FrontierRegions and non-Pakistanis.

Source: Pakistan Population Censuses, 1951, 1961, 1972.

The Future - Population Projections

2.08 Given the existing structure of the population, it is possibleto make some reasonable assumptions about future growth patterns. Whilethe future can never be predicted with certainty, it appears that drasticchanges in fertility, mortality, urbanization and other factors are unlikely.Furthermore, the existing age structure of the population is known, and isa major determinant of growth patterns, particularly for the more immediatefuture. Four series of projections have been prepared for Pakistan for the

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next 40 years. 1/ These projections are not intended to predict thegrowth of the population in Pakistan, but to illustrate the range of likelyalternative population and age structures under various assumptions.

2.09 In all four series, mortality is assumed to continue to declinegradually and not to be affected by levels of fertility or migration.Various assumptions have been incorporated for fertility, varying fromconstant fertility at present levels to an extreme case of an immediatedrop to replacement level fertility. The rate of urbanization, which affectsthe overall birth rate, is assumed to be related directly to the rate ofgrowth of the rural population (see Appendix 1). Finally, to project thelabor force supply, the participation rates obtained in the 1972 Census formales aged 15-64 are assumed to remain constant in the future; the rates forfemales are assumed to increase linearly to reach 1975 United States femaleparticipation rates by the year 2022. Participation rates for persons under15 or over 65 years of age are assumed to decline gradually to zero.

Table 4: TOTAL POPULATION FOR SPECIFIED YEARS UNDERDIFFERENT FERTILITY ASSUMPTIONS, 1977-2017

(Millions)

Growth RateProjection Series 1977 1987 1997 2007 2017 1977-2017 (%)

1. Constant Fertility 80 113 168 255 391 4.02. Moderately Declining

Fertility 80 110 156 217 286 3.23. Sharply Declining

Fertility 80 100 116 138 159 1.74. Replacement Fertility

After 1977 80 87 101 115 126 1.2

Source: Appendix 1.

2.10 Overall Effects. The first projection, with constant fertility anddeclining mortality, results in an increasing rate of natural growth. Thecrude birth rate would actually rise slightly, from 44 to 47 per thousand,due to the shifting age structure of the population. Under these conditionsthe population would increase fourfold in 40 years and experience an average'growth rate of 4% per annum. The probability that this will occur is verylow, however, because the same socio-economic factors that result in reducedmortality are usually found to affect fertility. If fertility does not de-cline, the excessively fast growth of the population could possibly initiateforces which would increase mortality again. Projection series 1 is bestviewed, therefore, as providing an upper limit to the growth of the population.

1/ The detailed projections with their assumptions are contained inthe Appendix.

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2.11 Projection series 2 assumes a modest decline in fertility by theyear 2017. In terms of total fertility, the average woman would have 4.1children versus the present level of 7.9. The crude birth rate would fallfrom 46 per thousand to 42 by 1997, and to 30 by 2017. Some gains in socio-economic development with a moderately effective family planning program wouldbe required to produce this result. However, even with this decline infertility, the structure of the population is such that the growth rate wouldaverage 3.2% during the next 40 years. Thus modest gains in fertilityreduction will only cause the population growth rate to stabilize at presentlevels.

2.12 Projection series 3 assumes that fertility will decline markedlybetween 1977 and 2017. The Government's objective of a birth rate of 33.5 by1983 is assumed to be reached, with a further decline to 19 by the year 2017.Thus, an overall population growth rate of less than 2% would result duringthe 40 year period. To realize this projection, however, the Governmentwould be required to implement a very strong program of fertility controlwhich, in addition to providing family planning services, would have toinclude social development measures (health, education and working oppor-tunities for females) and possibly even economic incentives for the effectivepractice of family planning.

2.13 Projection series 4 is presented simply for illustrative purposes.It assumes that fertility will fall immediately to replacement level. Evenunder this severe assumption, the population would continue to grow at anannual rate of approximately 1.2% per year, reaching 108 million by 2002and 127 million by 2017. This projection, therefore, shows the absoluteminimum growth in population that could possibly be achieved. It is mostlikely that the actual population pattern will fall somewhere between thatindicated by projection series 2 and 3. In the following discussion referencewill be made only to these two projections, and they will be referred to as"high" and "low," respectively.

2.14 Impact on Education. The cost of rapid population growth can beseen clearly in the numbers of children that will require education, par-ticularly at the primary level. At present, only about 5.1 million children,or 44% of the population aged 5-9, are enrolled in primary schools. Thestated objective of universal primary education implies that 11.2 millionnew school places will be required before 1987 if the high growth projectiontakes place (see Table 5). If the population grows as in the lower projection,the need for new school places is decreased by 2.1 million, meaning 9.1 newplaces by 1987. Furthermore, the total number of children in primary schoollevels off under the low projection at between 14-15 million, compared to anever expanding number under the high projection, which eventually reaches38 million by 2017. The lower population growth projection could entail acapital saving of Rs 22.5 billion over the 40 year period. In addition, Rs 94billion could be saved in recurrent costs. 1/ These rough estimates assume

1/ These estimates are based on a capital expenditure of Rs 1,000 pernew pupil place, and recurrent costs of Rs 210 per year.

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universal primary education. In fact, unless the population growth rate isbrought under control, it seems unlikely that universal primary education willbe attained.

Table 5: POPULATION OF SCHOOL AGE FOR GIVEN YEARSUNDER TWO PROJECTIONS OF POPULATION

(Millions)

Projection Growth Rates (%)Series 1977 1987 1997 2007 2017 1977-1997 1997-2017

Primary School-Age Group 5-9

High 12.1 16.3 23.4 31.8 37.7 3.3 2.4Low 12.1 14.2 9.9 13.7 15.2 -1.0 2.1

Secondary School-Age Group 10-14

High 9.9 14.0 19.3 27.7 35.2 3.3 3.0Low 9.9 14.0 12.3 11.5 15.0 1.1 1.0

Labor Force

High 23.5 33.9 50.1 75.0 112.0 3.8 4.0Low 23.5 33.9 48.3 60.9 74.2 3.6 2.1

Source: Appendix 1.

2.15 Prospects relevant to secondary education are not much different.At present, secondary school students number about 1.7 million, while thenumber of persons aged 10-14 is about 9.9 million, giving an enrollmentratio for the age group of 17%. The population aged 10-14 should be about14 million by 1987, regardless of the projection, since these childrenhave already been born. By 1997, however, the 10-14 age group might rangebetween 12.3 million and 19.3 million. By 2017, the corresponding numbersare 15.0 million and 35.2 million. Under the low growth projection, enroll-ment ratios could be maintained after 1987 with the capital stock existingat that time, since the population aged 10-14 will level off, or actuallydecline in some years. Under the high growth projection substantial invest-ments in secondary schooling would have to be made merely to preserve existingenrollment ratios (assuming no major increase in educational efficiency).

2.16 Employment. The number of people working or looking for work willnot be significantly affected by changes in fertility until 15 or 20 yearsafter those changes have taken place. The population of working age until theyear 1992 has already been born and can only be affected by large changes inmortality, migration or participation rates. These factors seem unlikely tochange much in the next 15 years. The labor force in 1992 will, therefore,

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number about 41 million persons, growing until then at an average rate of 3.8%per year. By contrast, during the ten years 1967 to 1977 employment grew atan annual rate of only 2.5% per year. The sharp acceleration in likely laborforce entrants poses a potentially serious problem for the economy. Somerelief can be expected through migration abroad, but this will have a limitedeffect on the total supply. Unless sufficient employment opportunities can begenerated by well designed growth and employment policies, the prospect ofincreasing unemployment and falling wages, particularly in the informalsector, appears inevitable. The magnitude of this potential unemploymentproblem, however, does not appear to be fully recognized by Government offi-cials or even by many outside observers. This arises from the fact that theaccelerating population growth of the last decades is only now beginning toaffect the size and growth of the labor force.

2.17 Only after 1992 can the labor force be affected by changes infertility patterns. While the lower fertility assumptions would reduce theprojected labor force by only about 2 million people by 1997, by the year2017 the effect would be more substantial, amounting to a difference ofover 20 million. The average rate of growth for the 1997-2017 period variesfrom 2.1 to 4.0% under the two projections. As mentioned earlier, eitherprojection assumes constant participation rates for males, an increasedparticipation rate for females, and declining participation for those underage 15 or over 65.

2.18 Income. Population growth will be a major factor in determiningthe growth of output and income. A lower growth of population could permita slower growth in consumption, greater savings and hence greater investmentand output. On the other hand, lower population growth, by reducing thedemand for goods and services, could conceivably lower the growth of output.Assuming, for the moment, that output growth is not affected by populationgrowth, it is possible that small changes in population growth could in thelong term have significant impact on raising per capita income. With a 5%growth rate of GNP, and a population growth rate of 3.2%, per capita GNP woulddouble in 40 years. On the other hand, if the population growth rate could belowered to 1.7%, as in the low projection, per capita income would rise by afactor of 3.6 times. If present per capita income is $170, then the dif-ference in the two projections results in a per capita income of either $340or $610. With the lower growth of population, per capita income would be80% higher.

2.19 The lower average per capita income projected with high populationgrowth conceals the potential of a deterioration in the distribution ofIncome. The inability to cope with a rapidly expanding population and laborforce could produce even higher levels of unemployment and underemployment,as well as downward pressures on labor incomes, and even more families livingbelow the poverty line. In such a situation, it would become increasinglydifficult to raise revenues to provide the social services necessary for theexpanding population, and programs designed to eliminate disparities in incomeand provide basic needs would not be implemented. In the next chapter, there-fore, issues concerning population planning are discussed in an effort tounderstand the possible policy options open to the Government.

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III. POPULATION PLANNING

3.01 The participation of the Government of Pakistan in population plan-ning dates back to the mid-1950s and has gradually increased from a very minoreffort at first to the point where it presently includes most types of familyplanning activities. The family planning services provided, however, havenot significantly affected fertility. Lack of progress is explained bysocio-economic conditions which are not yet propitious for a high demand forcontraception and by a delivery system which has not provided the quantityand quality of services required to meet the demand which does exist.Future progress in population control will depend on both of these factors,as well as on the priority given to population planning by the Government.

Socio-Economic Conditions and Fertility

3.02 Fertility and mortality rates are closely linked with level ofeconomic development. High fertility and mortality characterize countriesat a very low level of development; as development proceeds, countriesexperience a period of high fertility and low mortality, before evolving toa stage comprising both low fertility and low mortality. Pakistan, likemost developing countries, is still at the second stage of high fertilityand low mortality.

3.03 In poor societies, families tend to have larger desired and actualfamily sizes than in rich societies. One reason for this may be that poorfamilies perceive a need for more children to guarantee parental securityduring old age. If this is true, there will be an interest in a givennumber of children surviving at the time of the parents retirement. Ina society where women do not have economic opportunities and, therefore,cannot contribute to their parents support, there will be preferencefor male children and fertility will be higher to obtain a given numberof surviving sons. In addition, the higher the levels of infant andchild mortality the higher the fertility necessary to achieve a desirednumber of surviving children.

3.04 The low level of income in Pakistan, the low status of women inthe society and the high rate of infant mortality result in a large numberof children per family. The Pakistan Fertility Survey 1/ indicates thatthe number of children perceived as ideal by a married woman averages 4.2.There are differences, however, according to place of residence and educa-tion. The ideal number of children for women in urban areas is 3.9 comparedto 4.3 for women in rural areas. The ideal number of children is 4.3 forwomen with no schooling, 3.7 for women with primary education, and 3.2 forwomen with secondary or higher education. Given the fact that very fewwomen in Pakistan receive any education unless they are from high income

1/ Government of Pakistan, Population Planning Council. World FertilitySurvey: Pakistan Fertility Survey, First Report. October 1976.

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families, and that income in urban areas is on the average higher than inrural areas, it is apparent that income, education and urbanization factorsare all interrelated with regard to fertility rate.

3.05 The Pakistan Fertility Survey confirms a preference for sons. Thedesire for additional children among currently married women is higher forthose with a low number of living sons than for those with several livingsons. This result is the same regardless of the number of living children orthe age of the woman. Since women in Pakistan do not have much opportunityto participate in economically productive activities outside the household,their value as a source of economic security for their parents is greatlyreduced. The low status of women in Pakistan begins early in life with theirinferior position with respect to food, care and education in childhood.Restricted contact with the world (purdah), together with submission to theirhusbands in marriage, extends that status to their entire lives. The resul-tant feelings of inferiority obstruct the success of any family planningmovement. If women measure their value in bearing children (especially sons),and if their only personal rewards are found in the nurturing function andsocial contact with other women and children, they will not cut off theirsource of self-worth. The potential contribution of women to Pakistan'sdevelopment is only beginning to be recognized. With greater opportunity foreducation (basic literacy), employment, and improvement of skills (includingdomestic ones), women can contribute substantially to improving their ownsocio-economic situation and that of their families.

3.06 The relationship between infant mortality rates and birth rates isclear although the direction of causality has not been established. Table 6shows the distribution of 86 countries according to infant mortality and crudebirth rates. Countries with an infant mortality rate of 100 or more tend tohave birth rates generally in excess of 40 per thousand. Pakistan, with aninfant mortality rate of 130 and a crude birth rate of 44, falls into thisgroup. Countries which have succeeded in lowering infant mortality, however,have markedly lower birth rates. The majority of countries with infantmortality rates of 25 or less have birth rates of 20 or less. In otherwords, success in lowering infant mortality in Pakistan would probably beassociated with a significant decline in fertility.

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Table 6: DISTRIBUTION OF COUNTRIES ACCORDING TO BIRTHRATES AND INFANT MORTALITY RATES /a

Deaths/to children under one year of age/perthousand births

Births perthousand Less than 100 andpopulation 25 35-49 59-99 Over Total

Under 20 15 5 2 - 2220-29 6 6 3 - 1530-39 1 4 5 5 1540 and over - 4 12 18 34

Total 22 19 22 23 86

/a 86 countries for which data on infant mortality were availablefor 1970 are included.

Source: World Bank, World Tables 1976. The John Hopkins UniversityPress, Baltimore, 1976.

3.07 The level of infant mortality is likely to influence fertilitydecisions in several ways. The most important one may be that a coupleplans to have a number of births sufficient to obtain the desired number ofsurviving children and thus must compensate for likely deaths. In this case,a rapid decline in infant mortality will produce an excess of survivingchildren. This appears to be the situation in Pakistan; a large proportionof women with completed families have a number of living children greaterthan that which constitutes their ideal family size.

3.08 The level of poverty, the low status of women and the high infantmortality rate appear to be major factors related to high fertility inPakistan. A program to reduce fertility must, therefore, be complementedby policies to improve the standard of living, provide more education andemployment opportunities for women, ameliorate the living environment andprovide better health services. This is not to imply that good familyplanning services should not be provided before poverty is eliminated. Atpresent, there is evidence of a great need for family planning servicesamong the people who have already completed their desired family size.

The Family Planning Program

3.09 Although family planning activities in Pakistan were started shortlyafter Independence, Government participation only began with the First Five-Year Plan (1955-60). Initially, this participation took the form of supportof private groups, and it was not until the Second Five-Year Plan (1960-65)that the Government both adopted a firm policy to reduce the birth rate by

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providing family planning services and took public responsibility for theprogram. Confronted with an estimated crude birth rate of 50 births perthousand population, the Government, in the Third Five-Year Plan (1965-70),set out to reduce it to 40 by 1970. The goal was not achieved. The goal ofthe draft Fifth Plan (1977-83) was to reduce the crude birth rate to 33.5 by1983.

3.10 Delivery Systems. Responsibility for implementation of the familyplanning program and the strategy for the provision of services have changedover the years. In the First Plan, as mentioned, provision was made forGovernment help to voluntary organizations. In the Second Plan the healthsystem was required to supply family planning services. Later, a specialorganization involving the federal and provincial governments was createdand services were provided by dais (traditional midwives). These dais wereilliterate part-time workers who received very low salaries, and familyplanning was not compatible with their usual occupation of delivering babies.In addition, though the program placed strong emphasis on clinical contracep-tives, especially the intrauterine device (IUD), training and supervision forthese workers was practically nil.

3.11 The Continuous Motivation System (CMS) began with an experiment inSialkot District in 1969 and was extended to cover most of the country in1973. The basic purpose of the system was to provide the target populationwith continuous encouragement to accept and practice contraception. Thiswas to be done with frequent visits (four times a year) by a team of maleand female workers (a male to visit males and a female to visit females).These workers were to be educated (high school) to ensure the ability tokeep records, and to be married (to each other if possible), thus facilitatingcontact with married couples. Communication with the target population was tobe enhanced by requiring the teams to live in the village where they worked.The workers were to be well paid so that full time commitment to the programwould be ensured. They were expected to keep records of each village house-hold, to encourage practice of contraception and to provide supplies. Inaddition, the work of each team was to be supplemented by Family WelfareClinics staffed by well trained Lady Welfare Visitors (LWV) who would be incharge of inserting IUDs, following up the cases and providing some maternalchild services. All personnel were to be well supervised by a clearly desig-nated line of supervisors including Population Planning Officers, SeniorPopulation Planning Officers, District Technical Officers and DistrictPopulation Planning Officers.

3.12 To complement the CMS, the Government adopted the Inundation Systemin early 1975. This system was devised on the assumption that people will usecontraceptives if such supplies are readily available. To insure maximum use,therefore, contraceptives were to be distributed to every household, initiallyfree of charge if necessary. For this purpose a large quantity of condomsand pills was imported to ensure universal availability. They were to bedistributed through the workers in the CMS and a large number of retailers.

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3.13 Program Performance. The performance of this program was firstreviewed by the Bank in 1974 1/ and again in 1976. The 1976 review revealedthat most of the problems affecting the program in 1974 were still present,although efforts had been made with success to solve a few of them. The 1974Bank document concluded that the program effectively covered only about 6.5%of the eligible couples in the country, and that the maximum effect on fer-tility could only be of about the same magnitude. The Pakistan FertilitySurvey, 2/ conducted at the end of 1975, indicated that only about 6% of therelevant women in the country were practicing contraception in a continuousmanner and that the effects on fertility of past efforts had been negligible.There is no evidence to indicate that the situation has since changed.

3.14 This does not of itself indicate that the concept behind theContinuous Motivation System was invalid since the CMS was never fullyimplemented. The scheme encountered numerous administrative constraints;the required personnel were not available at the village level; the peoplehired were not adequately trained; neither the planned supervisory organiza-tion nor the supportive network of communications, supply and logistics, andresearch and evaluation were ever implemented. The CMS scheme as originallyconceived had considerable merit but was probably appropriate to a moreadvanced socio-economic environment.

3.15 The organizational problems were due in part to a lack of coopera-tion between the health departments and the family planning boards at theprovincial level, where the program was to be implemented, and to the failureat the provincial level to delegate decision-making responsibility to thedistrict level. Until recently, policy and financing were provided by theFederal Government, with implementation the responsibility of the provincialgovernments. The district and local levels could do little except followinstructions, having no authority to adapt the program to local conditions.

3.16 A number of factors contributed to the personnel problems.. CMSworkers were not given civil service status and related benefits accordedall other Government employees. The program was utilized as an opportunityfor political appointments at the provincial level. Because persons withthe desired qualifications (matriculates residing in the villages wherethey had to work) could not be found, it was necessary to utilize peoplefrom outside the villages or with less than the required schooling.

3.17 Training problems occurred in the initial stages of the CMS. Therapid expansion of the system required the training of a large number ofpeople when the program did not have that capability. The agency in chargeof training was inadequate; guidelines were lacking to identify training

1/ Roberto Cuca and Lee L. Bean, "Family Planning in Pakistan: A Reviewof the Continuous Motivation System." World Bank, Washington, D.C.(mimeo), February 1975.

2/ Government of Pakistan, Population Planning Council, World FertilitySurvey: Pakistan Fertility Survey, First Report. October 1976.

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needs and content; there was little communication between the training staffand field operations; and the training periods were too short and the groupstoo large for effective learning. In an effort to correct this situation,a Population Training Center has been formed, independent of the earlierTraining, Research and Evaluation Center (TREC). It will be some time,however, before the results of this addition can be observed.

3.18 Inadequate supervision was another hindrance to successful imple-mentation of the CMS and can be traced to low morale among the supervisorypersonnel. This originated in their lack of civil service status, the absenceof comprehensive job descriptions, a dearth of authority to exercise thesupervisory role properly, inadequate training, and office space and trans-portation problems.

3.19 Communications failures resulted from problems between the centralcommunications unit and the corresponding units in each of the provinces andfrom the absence of testing and evaluation of materials. The central unit'sdecision to allocate most of its time to production rather than developmentof materials and strategy also weakened the communication effort. A newdirectorate of communications and publicity, organized in mid-1976, is tryingto deal with these problems.

3.20 The program also suffered from inadequacies in both quantities ofsupplies and the logistics system to distribute the supplies which were avail-able. Again the rapid expansion of the program with its emphasis on pillsand condoms, coupled with poor planning and a shortage of the needed materials,contributed to the problem. In addition, the supplies available were notproperly distributed according to needs; in some districts there was a surfeitwhile in other districts visits were made without any supplies. The problemof an adequate quantity of supplies was solved in 1975 with the inundationprogram, but logistics problems still remain.

3.21 Research and evaluation efforts were another weakness of the program.Program managers gave low priority to data not dealing with disbursement ofcontraceptives. Contributing to the problem was the dearth of personnelqualified to do research within the organization and the little use made ofresearch resources in other institutions. Over the last two years, most ofthe research effort was devoted to the Pakistan Fertility Survey, with verygood results. More operational research, however, is still needed.

3.22 Although the problems today are still not very different from thosein 1974, some progress has been made and there is evidence that the Governmentis beginning to act more aggressively to correct them. Two factors appear tohave been important in convincing the Government that action was needed. Thefirst was the Report of the Committee on the Population Planning Program, 1/which had been appointed by the Prime Minister in January 1975. This Report,

1/ Committee constituted by the Prime Minister vide Cabinet DivisionSecret No. 20/CM/75. Report on the Population Planning Programme.August 15, 1975.

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presented in August 1975, outlined the problems with the program and offeredspecific recommendations to improve it. These recommendations were not re-stricted to family planning activities; they included some social measures aswell as specific development efforts to increase demand for family planning.The second factor was the publication, in October 1976, of the results of thePakistan Fertility Survey (PFS), which had been conducted at the end of 1975.The results of this survey, as mentioned above, indicated that the program hadfallen far short of meeting its expectations.

The Draft Plan for Population Planning

3.23 The outline of a new approach was included in the draft FifthDevelopment Plan. The new plan for the population planning program.involvedimportant changes in the areas of motivation, provision and integration ofservices and organization and logistical support.

3.24 Motivation. The house-to-house motivational work by male-femaleteams, the basis of the CMS, is being phased out. In its place the new Plancontemplated a three pronged strategy. First, more emphasis would be givento clinical services, somewhat neglected in the past. In each clinic therewould be a Lady Welfare Visitor (LWV) who would provide health and familyplanning services as well as motivational activities. The LWV would beassisted by two female workers who would do follow-up, resupply and somehome motivation. A second area of effort would be the mass media, par-ticularly radio. The mass media campaign would be handled by differentprivate advertising agencies, each charged with the promotion of a particularcontraceptive method. A central committee in the Population Planning Divisionwould coordinate the campaign. The third vehicle, for motivation, to be intro-duced on an experimental basis, would be the identification and utilization of"influential women" in villages. In each of 5,000 villages one influentialwoman would be selected and trained to motivate the population. At presentsome thought is also being given to using hakims and homeopaths in the programand plans for an experiment of this nature are underway. With this attack atthe clinical, mass media and village levels, the Government expected to reachthe whole of the target population.

3.25 Service Delivery. Several important changes were planned in thedelivery of services. The new Plan had three main emphases: clinical ser-vices, more reliable contraceptive methods (IUD and sterilization), andcommercial distribution of condoms and oral contraceptives. The clinicalemphasis aimed in part at improving the services provided in the FamilyWelfare Clinics (FWC), the number of which would be expanded. Each clinicwould provide basic health and family planning services by utilizing, asmentioned above, a Lady Welfare Visitor well trained in both types of ser-vices and able to insert IUDs. She would be assisted by two family planningworkers; this would allow the clinic to remain open full time and permitimproved follow-up of clients. In addition to the FWCs, all health facilitieswould provide family planning services, either by health staff or by Popula-tion Planning Division staff posted in the health clinics. By making clinicalservices the center of the program, more active promotion of the IUD would bepossible, thus supporting the new emphasis on more effective methods. The

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program also included the expansion and improvement of sterilization centerswhich would attend clients referred by FWCs and maternity hospitals. Thecommercial distribution of condoms and oral contraceptives was aimed atinsuring that stocks and supplies would be available in a large number ofshops in the country. Distribution would be made through three private firms;two would distribute condoms, the other would be responsible for oral con-traceptives.

3.26 Service Integration. One of the most important changes in the newprogram was the integration of family planning with other activities in thecountry. Thus, family planning services would be integrated with health ser-vices, population education would be combined with other activities of theMinistry of Education, and family planning components would be included in thedevelopment programs of other ministries. Integration with health would be intwo directions: (1) family planning services would be provided in all healthfacilities in the country, and (2) the family welfare clinics would providematernal and child health services. A three-tier committee system (federal,provincial, district) would insure that there was no duplication in services,as had sometimes happened in the past. This integration would thereforeincrease the country's number of facilities for both health and family plan-ning. With respect to population education, collaboration with the Ministryof Education has already resulted in family planning training of primaryschool teachers and the introduction of population education elements intothe primary school curriculum. Present plans call for these two reforms tobe implemented also at the secondary level and, later, at the college level.The Population Planning Division is working with the Ministries of SocialWelfare, Local Government and Rural Development, Production, and Agricultureto study the feasibility of including population planning components in theprojects of those ministries. Similar efforts are underway to investigatethe utilization of semi-autonomous agencies, such as Pakistan InternationalAirlines, for the provision of family planning through their health servicesprograms. In the past, lack of integration has been one of the main reasonsfor the limited success of the program; the present steps in that directionshould, therefore, prove helpful in increasing acceptance and practice offamily planning.

3.27 Organization. In concert with the draft Plan for the populationprogram, certain organizational changes have taken place. In March 1978 theGovernment announced the merger of the clinical function of population plan-ning with the provincial health services. Motivation, training, research,planning and coordination, education-and overall responsibility for populationplanning remained the responsibility of the Federal Government. The changewas intended to ensure a common policy approach to population planning andcoordination of the program with the basic health services.

3.28 Logistical Support. Plans are now being developed to upgrade thequality of training given to program personnel and to improve the logisticssystem. The adaptation of the statistical system to the new plans is alsounder way.

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3.29 The Prospects for Program Success. Past family planning effortshave not had a significant effect on the fertility rate in Pakistan. Thesocio-economic conditions have not been conducive to fertility decline andthe plans have not been appropriate-to the conditions of the country. Inaddition, firm Government commitment to population planning has been lacking.Whether future programs will have more success will depend on the existenceof a market for family planning, adequacy of resources for the program, thecapability to reach the available market, and sustained Government support forthe program.

3.30 The Market for Family Planning. The socio-economic conditionsusually associated with positive attitudes toward family planning and withcontraceptive practice have been slowly improving in Pakistan over the pastfew years. The infant mortality rate has declined to about 130 deaths perthousand births; the proportion of girls of primary school age enrolled inschool is increasing; and the proportion of women participating in economi-cally productive activities outside the household has risen. Although theactual proportions are still very low and characteristic of a country at theinitial stages of development, they have been sufficient to create a demandfor family planning. According to the Pakistan Fertility Survey (PFS), about17.4% of currently married women do not want additional children; althoughthey are not practicing contraception at present, they are not opposed to theidea and, therefore, may practice it in the future. This constitutes asizeable ready market which, if effectively supplied, could produce a declinein the birth rate from the present 44.5 to about 37 births per thousandpopulation by 1983. This market is likely to expand in the future as socio-economic conditions improve but unless services are readily available, thepotential fertility decline will not materialize. It is unlikely that thetarget of a birth rate of 33.8 births per thousand population by 1983 will bereached. This target, like previous ones is very ambitious. Even to reachthe birth rate of 37 will require a great effort. The setting of unrealistictargets may, as in the past, create skepticism and possibly affect financingfor the program (see below).

3.31 Resource Availability. Pakistan is presently facing severeresource constraints. This inevitably will influence the allocation offunds for population planning. More important, however, are the doubts bothwithin the Government and among foreign donors about the advisability ofdevoting resources to a program which has shown little result in the past.

3.32 This skepticism is understandable. However, past efforts in familyplanning, although not effective in reducing the birth rate to the targetspecified, have at least had some impact in increasing knowledge of contra-ception and possibly in changing attitudes toward family size. The PFS showsthat 71% of married women know of at least one effective method of contracep-tion. Moreover, only 38% of currently married women do not intend to usecontraception at any time. Knowledge of contraceptives reached 93% of the 29%of married respondents contacted by the program. Among these women, 24% hadat some point practiced contraception, compared with only 2% of those not

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having contact with the program. These figures indicate the changes thathave taken place in the country over the last two decades and the potentialimpact of a well-managed and adequately funded program.

3.33 Can the New Plan Reach the Market? Assuming that adequate resourcesare available, the success of future population planning efforts will hingeon whether programs will be implemented better than in the past. Implementa-tion will depend on the extent to which the market can be localized so that

resources are put into the areas with higher potential; the success ofintegration with health services so that coverage can be expanded; and the

effectiveness of the training and supervision of the workers in motivatingthem to achieve the desired results.

3.34 Until now, the strategy of the program has been, to cover the wholecountry with services. There is no question, however, that some areas of thecountry are much more receptive to family planning than others, and that dif-ferent services may be required in different areas. A study of the resultsof the PFS is needed to determine the characteristics of acceptors and onthis basis the concentration of possible future acceptors. Furthermore, the

PFS revealed that a large proportion of married women did not want morechildren but were not practicing contraception. The reasons for this arenot known; it is necessary to determine the type of services desired and theconditions under which women would accept contraceptive practice. Such a

study would assist in restructuring services to reach the potential marketand would help ensure the most effective use of available funds.

3.35 Although health services now reach only about 20% of the population,integration of health with family planning could expand both health and familyplanning services without equivalent expansion in the budget. Planned expan-sion of the health system should also improve coverage. Integration appearsto have particular potential at the level of the clinics, for example bymaking it possible to have similar training courses for Lady Welfare Visitorsand Lady Health Visitors and by standardizing the clinics and avoiding dupli-cation. In addition, studies on utilization of clinics can provide guidelinesfor both health and family planning on the type of services required bydifferent communities and the location of different types of clinics.

3.36 The program in the past did not lack personnel, but it lacked well

motivated and trained personnel and proper supervision. The Government is

aware of this problem and has put greater emphasis on both training andsupervision. Training, however, is not well developed at present and will

require special attention. The formulation of communications activitiesis also still at an early stage.

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IV. THE HEALTH SYSTEM

4.01 It was pointed out earlier that improvement of the standard ofliving of Pakistan's population is dependent on lowering the rate of popula-tion growth. Efforts to improve health, and the consequent lowering of thedeath rate, may therefore appear counterproductive. This is not so, however,for three reasons. First, as indicated in Chapter III, a decline in the in-fant mortality rate may be a prerequisite to any decline in fertility. Second,improvements in health will not only reduce mortality but will also improvethe learning capacity of children while in school, and increase their pro-ductive capacity during their adult years. Finally, provision of healthservices distributes some of the benefits of economic development to thepoorest classes, and thus helps in reducing poverty and welfare disparities.

The Health Situation

4.02 Pakistan today faces, although to a lesser degree, the same healthrisks which prevailed at the time of independence three decades ago. Theseinclude widespread, but preventable, communicable diseases; moderate to severemalnutrition, particularly among growing children and women of reproductiveage; lack of, or inadequate, facilities for waste disposal and clean watersupply; and high fertility resulting in a high health risk for mothers andtheir offspring. While this description applies to urban slum areas, it isthe rural poor (70% of the total population) that are most affected. Giventhe nature and causes of the dominant disease patterns, the most appropriateremedy appears to be simple treatment, both curative and preventive. Theexisting medical services fall short of fulfilling this purpose, especiallyfor the rural poor, only about 5% of whom now have access to health care.Moreover, the existing facilities are frequently understaffed and poorlyequipped; these factors contribute to their low utilization by the targetpopulation.

4.03 Mortality and Morbidity. The leading causes of death in Pakistanare common respiratory infections, diarrhea, congenital abnormalities, tuber-culosis, malaria and typhoid fever. Table 7 shows the distribution of deathsby cause in 1971. Except for the recent eradication of smallpox, the pictureis the same today. The appropriate focus for health programs, however, isnot death prevention, but rather maintenance of productive life. Statisticson the morbidity and debility associated with illness would be more usefulin approximating the value of health to society. Unfortunately, the qualityof morbidity data in Pakistan is poor. Except for a few isolated surveys,one is forced to extrapolate a picture of the morbidity conditions from theavailable mortality data. Thus, for Pakistan, the major contributors tomorbidity are gastro-intestinal, parasitic and respiratory diseases. Thefrequently associated malnutrition goes unrecorded on clinic visit chartsas well as on death certificates. The Baseline Survey of Ferozewala andGajju Matta 1/ (two villages in Punjab) carried out in 1974 gives some

1/ Government of Punjab, Baseline Survey of Ferozewala and Gajju Matta.(Punjab), conducted by the Institute of Hygiene and Preventive Medicine.Lahore, 1975.

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insight into the level of morbidity found in a typical village setting. Rough-ly 28% of the people had malaria; 99.5% of the stool examinations showed worminfestations; and children under five averaged 5.6 bouts of diarrhea per year.In addition, 33% of the adults were diagnosed with trachoma; 87% of thechildren had decayed or missing teeth and 95% suffered from serious gumdisorders.

4.04 In the last thirty years there have been considerable improvementsin the health status of large portions of the world's population, Pakistanincluded, as evidenced by the lowering of mortality and morbidity rates. Inall cases, these changes have resulted from economic and social modificationstogether with measures specifically aimed at disease prevention and cure.Kingsley Davis 1/ suggests that one of the major factors for health improvementon the Indian subcontinent was the control of famine, facilitated by improvedtransportation and storage of crop surpluses, and expanded irrigation systems.There is, of course, variation from country to country, but in general therural populations have benefitted the least in terms of improvement in health.The problems of other groups are also clear in Pakistan. The infant mortalityrate is estimated to be around 130 deaths per thousand live births. Approxi-mately 17% of all children born die before age five. The longer life expec-tancy for males in Pakistan is the reverse of that seen in developed countriesand indirectly reflects the sex preference for male children and the lowerposition of women in the culture.

The Causes of Poor Health

4.05 Pakistan's health problems stem to a large extent from extremepoverty, especially in the rural areas. More specifically, the genesis ofthe leading killers can be traced to low levels of nutrition, poor housing,inadequate supply of uncontaminated water and low standards of environmentalsanitation and personal hygiene. The situation is exascerbated by the deficitin health services to meet family health needs in their simplest terms, al-though the health care gap is filled somewhat by the efforts of the indigenousmedical practitioners.

1/ Kingsley Davis, The Population of India and Pakistan (New Jersey:Princeton University Press, 1951).

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Table 7: ESTIMATED DEATHS BY CAUSE

Cause of Deaths Pakistan Urban Areas Rural Areas(Total)

Tuberculosis 26,272 2,289 23,983Bacillary dysentery and amoebiasis 11,896 2,305 9,591Cholera 15,861 3,070 12,791Smallpox 25,679 1,700 23,970Malaria 49,454 6,284 43,170Typhoid fever 156,614 23,900 132,714Diabetes mellitus 5,394 597 4,797Heart disease 8,464 3,135 5,329Kidney disease 0 0 0Neoplasms 1,599 0 1,599Peptic ulcer, appendicitis,

intestinal obstructions andhernia 5,664 869 4,795

Abortion, complications of preg-nancies, and childbirth 5,377 1,113 4,254

Congenital anomalies,and birth injury 34,877 4,503 30,374

All other infective andparasitic diseases 104,259 25,379 78,880

Cause unknown or inadequate 13,515 3,921 9,594Motor vehicle accidents 272 272 0All other accidents 4,535 272 4,263Suicide 0 0 0All other external causes 1,358 292 1,066Fractures, and all other

injuries 1,066 0 1,066Cause not given 1,599 0 1,599

Total 473,755 79,901 393,854

Source: Government of Pakistan, Ministry of Finance, Planning and EconomicAffairs, Statistical Division. "Population Growth Survey: 1971."Karachi, 1974.

4.06 The Nutrition Problem. In order to explain more clearly the highincidence of infectious diseases, one must evaluate the nutritional status ofthe population, a relationship long recognized. 1/ Nutritional factors gene-rally interact with infections in two ways: (a) malnourished persons are moresusceptible to infections; and (b) infections can precipitate malnutrition.The situation in Pakistan is no exception. Data found in several surveys

1/ N.S. Scrimshaw, C.E. Taylor and J.E. Gordon, Interaction of Nutritionand Infection, Monograph Series, No. 59, World Health Organization,Geneva, 1968.

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document the generally poor level of nutrition, particularly in children.Summary results of the 1969 National Nutrition Survey 1/ provide valuableinsights into morbidity due to malnutrition. The survey data indicate thatapproximately 46% of the families have inadequate caloric intake which meansthey are suffering from partial starvation. Of these families, 11% consumedless than 70% of the recommended allowances. Clinical data on skin foldthickness (a measure of body fat) indicate that the population examined werelean and thin. Worst affected were the pre-school age children. Height andweight measurements indicate almost universal growth retardation. A Pakistanchild of two years was found equal to the weight of a one year old Europeanchild. Genetic differences do not explain this variance. Vitamin A defi-ciency, iron deficiency anemia in pregnant and lactating women (affectingapproximately 50% surveyed), riboflavin and Vitamin C deficiencies and, inthe northern areas, goitre due to iodine deficiency were frequently detected.Most of the recommendations presented at the completion of the survey have notyet been implemented by the Government, including the establishment of anutrition policy to coordinate the efforts of the Health and AgricultureMinistries and applied nutrition programs.

4.07 Analysis of food balance sheets provide macro-level informationon the nutritional level of a nation. Table 8 presents data taken fromfood balance sheets to assess dietary changes at the end of the First, Second,and Third Five Year Plans. 2/

Table 8: DAILY PER CAPITA CONSUMPTION OF CALORIES, PROTEINSAND FATS FOR 1959/60, 1964/65 AND 1969/70

Daily Per Capita ConsumptionCalories/day Protein/day Fat/day

Year number grams grams

1959-60 1,809 44 201964-65 2,006 47 221969-70 (Provisional) 2,103 48 22

Source: Iqbal M. Akhtar, "Nutritional Aspects of National Diets," Governmentof Pakistan, Planning Commission, 1970.

4.08 Although some improvement has been made since 1959-60, the averagelevel of nutrition in Pakistan is still extremely deficient (optimal caloricintake appears to be about 2,350 calories). Of the calories consumed, roughly75% are in the form of carbohydrates from cereals, compared to 40% in developed

1/ Government of Pakistan, Ministry of Health, Labour and Family Planning,Directorate of Nutrition Survey and Research. "Nutrition Survey of WestPakistan (February 1965-November 1966)." Islamabad, 1970.

2/ The data presented includes Bangladesh because separate data for Eastand West Pakistan were not available.

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countries; the average daily protein consumption of 48 grams (as opposed toa recommended intake of 62.5 grams) appears to be deficient in animal proteins.Moreover, this macro-assessment only roughly estimates individual per capitaconsumption; the dietary situation of the lower income groups is worse thanthese figures indicate.

4.09 Water Supply and Waste Disposal. Environmental sanitation remains aserious problem in Pakistan and explains in part the very high incidence ofparasitic infections, cholera, typhoid fever and non-specific gastroenteritis.Less than 60% of the population have a potable water supply; about 15% haveaccess to basic sewerage facilities. Collection and disposal of excrement andrefuse in rural areas is virtually non-existent. The link between sanitaryconditions and health is demonstrated in several studies, although not allshow that better water supply systems and sanitation facilities result inimprovement in health. The answer to the paradox may possibly be found in thecultural practices of the population. For example, recent research 1/ inBangladesh found that the prevalence of cholera and other diarrheas in usersof high quality water from tubewells was no less than in non-users because ofthe persistent use of contaminated surface water by those who had access tothe clean water. Investment in improving water quality is likely to be in-effective in terms of disease reduction if the program does not also include avigorous health education component to improve personal and domestic hygiene.

4.10 High Fertility. High fertility rates affect the mortality of bothmothers and children. Almost everywhere in the world the expectation of lifeat birth is higher for females than for males. As mentioned earlier, this isnot true in Pakistan. Even in some developing countries where the general ruleholds true, female mortality is higher than male mortality during the child-bearing ages. This is due to complications of pregnancy and childbirth.Maternal mortality has also been found to increase with the age of the motherand with the number of pregnancies. 2/ The reasons for these deaths are basic-ally malnutrition of the mother, lack of prenatal medical care and the highproportion of deliveries that take place at home under unsupervised and un-sanitary conditions. A high proportion of deaths are due to the complica-tions of induced abortions which, because they are illegal, are performedin less than optimum conditions. In Pakistan, the Population Growth Surveyfor 1971 estimated that 29% of all deaths of women over age 15 were due to

1/ R.J. Levine, M.R. Khan, S. D'Souza and D.R. Nalin, "Future of SanitaryWells to Protect Against Cholera and other Diarrheas in Bangladesh,"The Lancet, Vol. II, No. 7976, 1976.

2/ Samuel W. Wishik and Susan Van der Vynckt, "Uncontrolled Fertility andMalnutrition." Report on an international conference held in Washington,D.C., on November 15-17, 1973 under the auspices of the Subcommittee onNutrition and Fertility, Committee on International Nutrition Programs,National Research Council, National Academy of Sciences.

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childbirth. 1/ Reduction of this cause of death will require better prenataland postnatal care, improved nutrition and a decrease in the number of un-desired pregnancies.

4.11 Stillbirths and infant mortality have been found to rise withincreasing age of mother and high birth orders. 2/ The Pakistan FertilitySurvey 3/ showed that the higher the number of bTrths a woman had had, thelower the survival rate for her children, independent of her age. The causesfor the lower survival rate, in addition to the high number of pregnancies,are the same as those producing the high maternal death rates: mothers'malnutrition and complications of delivery under unsanitary conditions.

4.12 The aforementioned data are especially illustrative of the natureof health conditions in Pakistan. While they can only be described as poor,the present situation is an improvement over conditions seen earlier. Theaverage crude death rate for Punjab during 1950-52 was about 28. 4/ InPakistan for the year 1973 it is estimated to be about 15. This declinehas not, however, affected equally all sections of the population. Infantand maternal mortality can be reduced still further. Table 9 shows thecomparison in national vital statistics among nations with GNP per capitacomparable to Pakistan. The remarkably low figures for Sri Lanka point to theimpact that widely-distributed, simple health care services can have in anotherwise undeveloped environment. It is important also to note the consid-erable disparity between rural and urban populations of Pakistan. Estimatesof infant mortality for the year 1971 are 138.1 in the rural areas against100.5 in the urban areas. The differential in age-specific mortality ratespersists throughout life and is particularly apparent in the comparisonbetween death rates for urban and rural females. Among the rural populations,the nomadic groups have least access to health services.

1/ Government of Pakistan, Ministry of Finance, Planning and EconomicAffairs, Statistical Division. "Population Growth Survey: 1971."Karachi, 1974.

2/ The Determinants and Consequences of Population Trends (New York:United Nations, 1973), p. 127.

3/ Government of Pakistan, Population Planning Council, World FertilitySurvey: Pakistan Fertility Survey, First Report 1976, p. All-29.

4/ Mohammed Afzal, The Population of Pakistan, Pakistan Institute of Develop-ment Economics (Islamabad, 1974), p. 17.

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Table 9: MEASURES OF HEALTH STATUS BY LEVEL OF PER CAPITA GROSSNATIONAL PRODUCT (GNP) IN SELECTED COUNTRIES

Life Expec-Per Capita Crude BNth Crude DNgth Infant tancy

Countries GNP a Rate - Rate Mortality /c Birth -

Bangladesh /d 80 50 28 140 36Indonesia 130 43 17 135 48Sri Lanka 120 29 6 50 68India 120 40 16 130 50Pakistan /e 120 47 17 115 50Philippines 280 44 11 80 58

La Figures are for 1973. Source: World Bank, World Tables 1976 (Baltimore:Johns Hopkins University Press, 1976).

/b Union Nations Secretariat, Population Division, Department of Economicand Social Affairs, "Selected World Demographic Indicators by Countries,1950-2000" (New York, May 28, 1975). Figures are from the medium variantassumption for the period 1970-75.

/c World Bank, op. cit. Figures are for 1970.

/d Figures for Bangladesh include the period of the Civil War in 1971-72.

/e The figures used in the World Bank's economic report differ from thefigures presented in the table, but were omitted to preserve consistencyof data. For 1972, the Bank estimates a crude birth rate of 46, acrude death rate of 15, an infant mortality rate of 130 and a life ex-pectancy at birth of 54.

The Health System in Pakistan

4.13 Public Health. The development of health services in Pakistandates back to very early times, as evidenced by the still popular hakims andvedic practitioners. Western medicine introduced under British rule did notsupplant this indigenous system but was limited principally to caring forgovernment servants and their dependents in the major cities. Over time theBritish did bring some health measures to the general population by means ofhospitals and dispensaries established through local governments. As a result,the tradition was established of local government responsibility for medicalcare to the people. This pattern is seen today where a "fee for service"approach to public medicine is practically unheard of in Pakistan. From theearly 1960s until their dissolution in 1971, the local union councils wereresponsible for monitoring and meeting local health needs. It was not until

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1972 that the Pakistan Government unveiled its first national health program,called the "People's Health Scheme," to provide basic health services.

4.14 In the Second Five Year Plan (1960-65) priority was placed for thefirst time on the provision of essential preventive and curative health serv-ices to rural areas. At the end of the Plan, 79 Rural Health Centers RHCs)had been constructed with staff sanctioned and programs initiated. Unfortu-nately, the programs lacked sound administration and a uniform plan fororganization and operation. Personnel posted in the centers found them-selves overwhelmed with curative work, frustrated with the rural isolationand lacking the normal amenities for themselves and their families. TheThird Five Year Plan (1965-70) called for 400 primary Rural Health Centersby the end of the Plan period. However, by 1969 only 83 RHCs and 250 BasicHealth Units (BHUs) were functioning (see Table 10). Those in operationsuffered from shortfalls in staff for all established categories; budgetdelays and controversy regarding the conceptual pattern of the rural healthprogram caused the disappointing performance. In contrast, the targetednumber of doctors, nurses, medical schools and hospital beds was almostachieved in the Third and Fourth Plans, as shown in Table 10.

Table 10: BENCHMARKS AND PHYSICAL TARGETS FOR THE THIRD ANDFOURTH FIVE-YEAR PLANS IN THE HEALTH SECTOR

Benchmark Target Benchmark Targetfor Third for Third for Fourth for Fourth

Item Plan 1964/65 Plan 1969/70 Plan 1969/70 Plan 1974/75

Doctors 9,725 13,100 13,400 16,150Medical Colleges 6 6 6 7Nurses 3,292 4,400 4,700 8,340Nurses Training Centers 21 - 21 25Hospital Beds 25,600 33,000 29,300 37,000a. Rural Health Centers 79 400 83 550b. Sub-Centers 225 - 250 1,650Lady Health Visitors 1,006 1,900 1,881 2,781Tuberculosis Clinics 87 127 95 195Tuberculosis Beds 2,400 - 3,000 4,700

Source: Government of Pakistan, Planning Commission, Fourth Five Year Plan,1970-1975, p. 231.

4.15 The People's Health Scheme, basis of the Fourth Five Year Plan(1970-75), was developed around the Basic Health Unit to serve between6,000-15,000 people as a sub-unit of a larger Rural Health Center. TheseBHUs and RHCs were then to refer the more seriously ill to "tehsil" hospitalsof 60 beds or district hospitals of 250 beds. Until now, implementation hasbeen limited to the northern areas on an experimental basis. The programhas, therefore, not been integrated into the existing delivery system andas a result lacks the necessary supervision for the health auxiliaries.Nevertheless, the positive community support for the program should en-courage further expansion and improvement of this effort.

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4.16 Social Security. Another important source of health care in Pakistanis the Social Security Program. In 1967, the Government introduced a pensionscheme for industrial workers to provide medical care to workers and theirdependents (average 5.7 dependents per worker). At present, there are threesemi-autonomous "Employees' Social Security Institutions" (ESSIs) in Pakistan,in Punjab, Sind and North West Frontier Province (NWFP). So far, the schemehas not been introduced in Baluchistan. In 1972, the employee's contributionto the plan was abolished and the employer's contribution was set at 7% ofwages for Punjab and Sind and 8% in NWFP. The benefits include coverage forsickness and injury, as well as minimal life insurance and survivors' pensions.The health coverage allows for general practitioner care including homevisits, specialist care in hospitals for in-patients as well as out-patients,drug and hospital costs, and maternity coverage by a specialist or midwife.An attempt to establish occupational health regulations has been made but noenforcement has occurred.

4.17 The total number of employees insured under the social securityprogram at the end of each fiscal year for the last five years is shown inTable 11. The number of insured workers has dropped off considerably from1973-74. This may be due in part to closure of factories; also in 1974workers who earned over Rs 500 per month lost their social security coverage.Since then, the ceiling has been increased to Rs 1,000 per month.

Table 11: TOTAL NUMBER OF EMPLOYEES INSURED UNDER SOCIAL SECURITY1971-75

Fiscal Year Punjab Sind NWFP

1971 139,376 151,592 10,3031972 171,302 165,226 13,4251973 204,115 182,071 19,9251974 224,413 190,506 25,0001975 213,155 168,460 26,000

4.18 The main medical facilities managed by the ESSIs include dispens-aries, injury treatment centers, mother/child health centers, polyclinicsand hospitals. While some of these are located in remote areas, the majorityare found near the industrialized urban centers. A recent study shows thatthe more remote a facility, the less likely it is to be adequately staffed.No social security medical facilities deliver family planning services, eventhough a high percentage of the clients are from the high fertility age group(20-34). Likewise, preventive measures are not addressed by the socialsecurity institutions for either the insured workers or their dependents.Some recommended preventive measures would include tuberculosis detectionand control, immunizations and health education. The standard of medicalcare under the scheme has not been evaluated but the decline in enrollmenthas been partially attributed to client dissatisfaction.

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4.19 The Private Sector. The role of private health services must beincluded in any discussion of Pakistan's health activities. Besides thewestern medical doctors in private practice, there are an estimated 40,000indigenous health workers in Pakistan. Four thousand of these are physiciansor hakims, trained in the Unani Medical System developed by the Moghuls.This is a system based on the Greek concept of--four humors which must bekept in balance to maintain health. The hakims are the most numerous andbest distributed of all available categories of health manpower in thecountry. They have an estimated average income of between Rs 6,000 to 10,000per annum. Their impact on the health status of their clients is not docu-mented, despite attempts dating back to the early 1920s to evaluate the roleof Unani and Vedic medicine. It is known that they oppose the principles ofmodern medicine and pay no attention to preventive approaches and familyplanning. The Indigenous Medicine Enquiry Committee of 1946 recommendedstate recognition and patronage of the indigenous system but it was not until1965 that the Government granted recognition, approved training curricula andregistered practitioners. There are now 9 Unani medical colleges with roughly1,100 students enrolled each year.

4.20 While some indigenous practitioners are located in urban areas,the bulk of them are in the rural areas. Dais, the indigenous midwives ofPakistan, still preside over the majority of births in the country. For ashort time they were used as family planning motivators but this practicewas discontinued as they were found difficult to control in a routine admin-istrative structure. A study of the dais used in the program indicates theythemselves were reluctant to participate in a program which lacked good medi-cal support. 1/

4.21 There is practically no evaluation of the role of the numerouschemists in Pakistan who dispense medicines of all types over the counter,without prescription. In Peshawar alone, there are at least 60 chemistswith shelves stocked with the latest American and European drug supplies.Vitamin preparations and aphrodisiacs are the largest sellers; contraceptivesare also frequently available. While the appropriate medication may be sold,it is often in insufficient dosage. This indiscriminate use of drugs caninduce drug-resistant strains of some organisms, with serious public healthimplications. The Pakistan Medical Society estimates that 64% of tuberculosiscases are now resistant to the common, inexpensive antibiotic therapy. Theresult is that treatment costs 40 times more than in non-resistant cases.At the same time, however, these non-professional sources of medical servicesare providing care which otherwise would be totally unavailable.

4.22 Expenditure in the private sector is impossible to assess with anyaccuracy. The estimated annual expenditure on private sector treatment isshown in Table 12. It is more than four times the amount spent in the public

1/ N.G. Hassan and A. Inayatullah, "The Dai Study: The Dai (midwife), aLocal Functionary and Her Role in Family Planning." A Research Mono-graph of the West Pakistan Family Planning Association (Lahore, 1969).

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sector and for FY 1973/74 raised per capita public and private health expen-ditures to about 2.4% of GDP. This is compatible with a WHO estimate oftotal expenditure on health accounting for 0.9 to 4.3% of gross nationalproduct in a number of countries. At any rate there is little doubt thatmuch more money (or payment in kind) is spent for health in the privatesector than by the Government. How effective this is in terms of real healthbenefits is debatable. The gap between indigenous and modern medicine is oneof class as well as professional points of view. Every effort should be madeto make full use of these indigenous workers in Government health programsand to upgrade their training and skills.

Table 12: ESTIMATED ANNUAL EXPENDITURE ON MEDICAL TREATMENT INPRIVATE SECTOR, 1974

Item Rupees (in millions)

Hospital beds 120Doctors in private practice 720Traditional healers 288Drugs and medicines 400

1,528

Source: Government of Pakistan, Planning Commission, Health andHealth Related Statistics (Islamabad, 1975).

Improving Public Health

4.23 The preceding review of Pakistan's health situation and programmingpriorities does not add anything dramatically new to the description of thehealth sector already presented in far more extensive studies than this. 1/Likewise, the recommendations for the most part are repetitious of thoseoffered in the past. 2/ The review does not attempt to survey all aspectsof the health sector, neglecting such areas as hospital care, environmentalsanitation and research programs. The focus has been on the primary healthcare delivery system which is intended to meet curative and preventive needsat the grass roots level.

4.24 Any recommendations to improve the health system must take accountof the limited financial resources, while at the same time using all avail-able human and physical resources to best advantage. Comprehensive health

1/ A. Furnia, "Syncrisis: The Dynamics of Health, No. XVIII: Pakistan,"U.S. Department of Health, Education and Welfare, Washington, D.C.(June 1976).

2/ M. Siraj Ul Haq and C. Stevens, "Some Account of the Current Situationand Recommendations Regarding Health Sector," Government of Pakistan,Planning Commission (Islamabad, 1975).

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care is not an immediately realistic goal; what is feasible is a more inte-grated health care program, balancing wants and needs and interrelating thecurative, preventive and promotive aspects of medicine. The present bias infavor of advanced technology is unwarranted since many of the most commondiseases respond to simple, unsophisticated treatment. Also, the urban biasis inequitable, given the urban-rural population distribution and the highermortality rates in rural areas. No perceptible dent in the health situationof the country can be made until these two biases are redressed. The suggestedchanges in program priorities, techniques and approach, while apparently log-ical, have been and will continue to be strongly opposed by the groups whobenefit from the continuation of the present health system in Pakistan. How-ever, the fact that these improvements are feasible and can have a profoundimpact on health has been demonstrated in several other countries. It will bethe task of the political leadership in Pakistan to see that the new directionsfirst cited in the People's Health Scheme take root and expand in accordancewith the demonstrated needs.

4.25 What is called for is an extensive Rural Health Program consolidat-ing the resources of the current vertical health programs, including familyplanning, into a more integrated delivery system. The package of servicesmust be comprehensive in content and extent. A mix of simple curative medi-cine to meet demands, and practical preventive and promotive efforts to insurecontinuity of health, is most suitable for Pakistan. Mass public healthapproaches to improve the environment only become effective when individualsand families learn to use the water and sewerage facilities correctly. Like-wise, personal medical services must combine both preventive and curativemedicine at each encounter. Until now the type of health services providedby the Government reflects the established priorities usually set by hospitalsand medical and nursing schools. Funds earmarked for preventive measureshave been meager in comparison to'curative costs; the bulk of the nationalpreventive health budget goes for malaria control alone. A strategy for expan-sion of paramedical manpower for rural areas must be rapidly implemented.These new health workers should cooperate whenever possible with local indi-genous health workers and originate wherever possible from those villagesthey will eventually serve.

4.26 The draft Fifth Plan envisioned a substantial shift from the presentdoctor-oriented strategy for delivery of health services to one employing aux-iliaries and community health workers. It also aimed to change the emphasisof these services from curative to preventive measures. The rural areaswould be the priority regions to receive these new workers and services.Support for environmental sanitation would be greatly strengthened. Theproposed health referral system hoped to link the village with the districthospital, with facilities staffed as indicated in Table 13.

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Table 13: PROPOSED HEALTH STRUCTURE

Level Population Health Facilities

Village 1,000 2 community health workers (CHW)--

one female and one male

Basic Health Units (BHUs) 10,000 4-5 health auxiliaries for pre-ventive work and outpatients

Rural Health Centers (RHCs) 50,000 2 doctors, 8 auxiliaries and 10 beds

Tehsil Hospitals 300,000 Surgical, medical, midwifery, ped-iatrics, dentistry and laboratory,X-ray facilities

District Hospitals 1,370,000 All modern facilities

Source: Government of Pakistan, Planning Commission, Working Papers forthe Draft Fifth Plan (1977-83). Part II. Islamabad, October 1976.

The model implied extensive manpower training, new construction and an ex-panded logistics system, with enormous implications in terms of recurrentcosts. By 1983, it was expected that 65% of the total population would becovered by this system; this would be a significant increase from the 20%

currently covered.

4.27 The implementation of any program for the improvement of healthservices in Pakistan would confront four major problem areas. These are:

(a) the effectiveness of the Federal Government in planningand directing provincial health programs;

(b) the country's capacity to develop an extensive Rural HealthProgram with well defined criteria to identify those most atrisk;

(c) the ability to integrate the present vertical health programs,including family planning, into a health system which cooperateswith the indigenous system and other' health service resources; and

(d) the establishment of a solid community organization base toensure fiscal support and societal participation in the health

care program.

4.28 Basic to the success of any primary health scheme is support from

the participants who themselves should have assisted in its planning andhave some control over the program. The results of Pakistan's earlier at-tempts at implementing rural health schemes should be reviewed. These are

reported in a study of the union councils' difficulties in carrying out their

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assigned health program under the Second Plan. 1/ Frequently, the councilswere unaware of their responsibilities and unfamiliar with their healthfunctions. The Provincial Health Departments were not involved in training orassisting the program since it was administratively under the Basic Democra-cies Department. Also, much can be learned from the evaluation of the 150rural health centers set up under the Fourth Plan 2/ and the analysis of therural health system initiated in the northern areas. 3/ In both cases, theinability to plan and manage the training, provide an improved system oflogistics for supplies and routinely supervise the auxiliary workers resultedin inefficient program operations. In both cases, there was demonstrated highutilization of services often to the point of over-extension and enthusiasticacceptance of the auxiliary worker by the majority of the community.

4.29 The draft Fifth Plan recognized the need to integrate all verticalhealth programs. The Plan's population program called for integration ofhealth and family planning in the field on an experimental basis with improvedservices at all levels. How this would work out in practice is critical; thepopulation program as it now exists would be the single most important sourceof human and physical resources to be added to the health effort. If theseresources do not become fully integrated with health, and if the healthprogram does not bring family planning services to all its outlets, popula-tion coverage is bound to fall well short of the targets in the draft Plan.

4.30 Over the Fifth Plan period, the Government projected a large expan-sion of human and physical resources for health (Table 14). In addition tomeeting the development budget requirements, the Plan would provide the prov-inces with a 20% annual increase in their non-development budgets. The Gov-erinent is well aware that the expenditures for the rural health programwould leave meager resources for on-going preventive programs, medical collegesand paramedical schools. Non-development expenditure for 1983 was estimatedto be more than the amount allocated now for the total health budget. It isobvious from this that the Government cannot expect to provide sufficientprogram funds itself and would need public participation. In principle, thecost of a local health unit should be supported at least partially by fundscollected from the population served. In fact, the study of the union councils'rural health program in 1969 showed that 93% of the councils were willingto contribute to local health cost financing. Communities, however, arenormally unwilling to support programs they do not to some extent control.Whether the Government can and will encourage the promotion of local respon-sibility and self-government remains to be seen. As has been demonstrated

1/ Akhtar Husain Awan, "The System of Local Health Services in RuralPakistan," Public Health Association of Pakistan (Lahore, 1969).

2/ Government of Pakistan, Planning Commission. "Evaluation of Projectfor Establishment of 150 Rural Health Centers!' (Islamabad, May 1976).

3/ Government of Pakistan, Planning Commission, A. K. Awan and ManzoorAhmed, "Preliminary Impact Survey of the Rural Health System ofNorthern Areas" (Islamabad).

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in other developing countries, effective local self-government can have asignificant effect on the promotion of health service and health care. Inputscan be generated in the form of free labor and land for construction of facil-ities, voluntary assistance to the health staff, partial fees for serviceand most important, peer pressure to encourage high utilization of theservices. Without revisions in organization and technology for health servicedelivery, health levels in rural Pakistan can only further deteriorate.

Table 14: PROJECTED EXPANSION OF HUMAN AND PHYSICALRESOURCES FOR HEALTH UNDER THE FIFTH PLAN

Resources to be Projected TotalBenchmark added under Resources byJune 1977 Fifth Plan /a 1983

Physical Facilities:

Hospital beds 44,048 25,000 69,048Rural Health Centers 242 898 1,140Basic Health Units/

Sub-centers 741 4,959 /b)Dispensaries 3,630 - ) 5,700MCH Centers 756 - )

Health Manpower:

Doctors 11,200 15,000 26,200Dentists 1,000 700 1,700Nurses 3,500 5,500 9,000Paramedics/auxiliaries /c 11,260 30,000 41,260Dispensaries /d 9,000 - 9,000Community workers 6,440 40,000 46,440

/a The coverage has been worked out on the basis of 65% of the populationending June 1983, i.e., 88 million.

/b The target of 4,490 BHUs includes any upgraded dispensary or MCHCenter conforming to the standards already described.

/c Includes Lady Health Visitors, technicians, midwives, auxiliariesand sanitarians.

/d Existing staff to be retrained as multipurpose workers.

Source: Government of Pakistan, Planning Commission, Working Papers for theFifth Plan (1977-83). Part II. (Islamabad, October 1976).

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V. THE EDUCATION SECTOR

Background, Structure and Objectives

5.01 Background. The 30 years since Independence have witnessed a sub-stantial expansion of education in Pakistan. Since 1947 school enrollmentsat all levels have risen from one million to more than 7 million students.Over the period 1966 to 1976 the enrollments at the primary level expandedat an average rate of 4.8%, at the secondary level of 6.3%, and at the uni-versity level pf 5.2%.

5.02 This expansion, however, has by no means solved the problems ofproviding adequate education in Pakistan, and it has created some new ones.Only about 31% of the 22 million children aged 5 to 14 are currently inschool. While 46% of the boys in the age group attend school, only 16% ofthe girls attend. These figures reflect both inadequate opportunity andlow demand for schooling among the poorer rural population. Many parentshave not found their children's education to be beneficial; education require-ments for job entry are often higher than the village school provides orparents can afford. The education system at present is not producing theskills needed for Pakistan's development and is excessively geared to pro-viding higher education for a privileged few.

5.03 Even the few children fortunate enough to reach school often lackbooks, pencils and paper. 1/ Lack of funds for building repair has oftenresulted in roofs leaking or collapsing and the crowding of two classes andtwo teachers into the same room. Attendance among teachers, especially inrural areas, is poor; it is not unusual for a teacher to sign the attendanceregister and then leave on personal business. Education officials have littlecontact with the village school, and little or no effort has been made toencourage and sustain local responsibility.

5.04 Thus, the period of rapid expansion of the education system hasraised a new set of questions. What should go on inside the schools? Towhom should school personnel be accountable? Should rote learning be replacedwith problem solving and exposure to village problems? What should be donewith the children who are still not in school? Can improvements be made inthese areas with more efficient resource utilization?

5.05 Structure. Pakistan's educational structure comprises five levels:primary (grades 1-5), middle (grades 6-8), high (grades 9-10), intermediate(colleges, grades 11-12), and degree (colleges and universities, grades13-14 plus). The Ministry of Education is responsible for all school educa-tion and some technical education. The universities are semi-autonomous, asare certain vocational and professional programs administered by other

1/ Planning Commission, Report on Primary Education, Islamabad, 1976 andMinistry of Education, Bureau of Educational Planning and Management,Rural Primary Education (Islamabad, 1977).

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Government ministries such as Agriculture and Health. The provincial govern-ments share educational administrative responsibility with the Federal Govern-ment. The provinces manage schools and supply operating budgets while theFederal Government provides development finance, policy formulation andcoordination. Certain city governments, such as Karachi's, also administerschools.

5.06 Since the mid-1960s education growth has been steady with an in-crease in schools, teachers and enrollments at all levels (Table 15). Between1965/66 and 1976/77 the total number of schools increased 64.4% and the numberof teachers 80.9%. For the same period total enrollments at all levels in-creased 65.2%. Thus, the number of students per teacher declined. The mostrapid expansion occurred above the primary level. The largest increaseoccurred in the secondary schools, where enrollments increased at an annualrate of 6.3%, or 85% for the entire period. Next in order of enrollmentexpansion were the high schools with a 5.2% annual rate of growth (64.9% forthe period), followed by primary education with an annual rate of growth of4.8% (59.4% for the period). University expansion was at an annual rate of4.1% (50.2% for the period). Female enrollments expanded more rapidly thanmale at all levels. Enrollment ratios for primary and secondary levels haveimproved since the mid-1960s (Table 16). At primary level, for example,approximately 44% of the 5-9 age group were in school in 1975/76, as opposedto 35.9% in 1965/66.

5.07 Using the measure of total educational expenditure as a percentage.of GNP, Pakistan compares poorly with several other Asian countries, as shownin Table 17. Only Nepal of the countries included in the table spends lesson education than Pakistan. However, the amount spent on higher educationas a percentage of total education expenditure is higher in Pakistan than theaverage for the other countries.

5.08 In colonial times the main objectives of the education system wereto train sufficient numbers of lower level civil servants in the governmentlanguage and routines, and to select and shape future members of the elite.The development of the system since Independence has tended to perpetuatethis elitist character of education and has taken insufficient account ofthe manpower needs of the country. This has resulted in a "mismatch" betweeneducation and the labor market, so that the educated often cannot- findemployment. Employers complain that the Government's vocational trainingprograms do not produce the kinds of skills they need. Primary studentsare not learning the simple reading skills needed for effective employmentand citizenship. University faculty and administrators complain of a needfor more money for salaries and buildings but often appear unconcerned aboutthe low utilization of university facilities, employer dissatisfaction andthe unemployment among graduates.

5.09 While some improvements are being made, two aspects of the situationseriously impede progress. First, there is a powerful lobby within the educa-tion establishment endeavoring to maintain the status quo. While some Govern-ment officials would like to make reforms, they have not found a way to supportthe reformers who are inside the education system. Second, the Government canonly introduce reform as fast as there are viable models for making changes,and there is sufficient leadership at high levels to support and adopt the newapproaches. Both the leadership and models appear to be lacking.

Table 15: GROWTH IN ENROLLMENTS, SCHOOLS AND TEACHERSBETWEEN 1965/66 AND 1975/76

1965-66 1970-71 1975-76

Total Total TotalEnroll- Number of Enroll- Number of Enroll- Number ofments Number of Teachers ments Number of Teachers ments Number of Teachers('000) Schools ('000) ('000) Schools ('000) ('000) Schools ('000)

Grand Total 4,308 37,762 136.1 5,623 50,195 181.4 7,116 61,439 246.2Male 3,329 28,387 104.7 4,241 36,451 131.9 5,242 42,627 174.1Female 979 9,381 31.4 1,382 13,744 49.5 1,874 18,812 72.1

Primary 3,202 32,930 74.9 4,067 43,710 96.3 5,104 52,562 129.5Male 2,455 24,658 57.5 2,998 31,613 69.1 3,680 36,283 90.3Female 747 8,272 17.4 1,069 12,097 27.2 1,424 16,279 39.2

Secondary 935 4,556 52.9 1,303 6,091 72.8 1,730 8,332 101.6Male 737 3,515 40.7 1,048 4,537 53.5 1,357 5,915 72.5Female 198 1,041 12.2 255 1,554 19.3 373 2,417 29.1

Higher 171 282 8.3 253 394 12.3 282 545 15.1Male 137 214 6.5 195 301 9.3 205 429 11.3Female 34 68 1.8 58 93 3.0 77 116 3.8

Sources: Government of Pakistan, Planning Commission Working Papers for Fifth Plan (1977-83), Islamabad, October 1976.Government of Pakistan, Ministry of Education, Bureau of Educational Planning and Management "PakistanEducational Statistics," Islamabad, Mimeo, 1976.

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Table 16: PERCENTAGE OF 5-9 AND 10-14 AGE GROUPS ENROLLED IN SCHOOL

Age Groups 1965/66 1971/72 1975/76

5 - 9 35.9 42.6 44.2Male 52.0 62.8 63.7Female 17.8 22.4 24.6

10-14 n.a. 16.0 18.3Male n.a. 25.8 28.7Female n.a. 6.3 7.9

Sources: Enrollment figures supplied by the Government of Pakistan'sPlanning Commission, October 1976. Population figures basedon 1961 census, 1972 census, as adjusted for the populationprojection (see population section of the report).

Table 17: EDUCATION EXPENDITURE AS A PERCENTAGE OF THE GNPFOR SELECTED COUNTRIES

---------- Percent of GNP …Country Per Capita Income Total Primary Secondary Higher

Papua 410 5.04 2.77 1.40 0.86

Malaysia 570 4.99 2.34 1.82 0.82Philippines 280 4.93 2.73 0.94 1.26Sri Lanka 120 4.90 1.73 2.89 0.27Korea 3.37 1.57 1.21 0.57

Burma 80 3.11 1.09 1.34 0.67Thailand 270 2.97 1.75 0.71 0.50Singapore 1,830 2.42 1.07 0.83 0.51

Indonesia 130 2.17 1.54 0.43 0.19Pakistan 120 1.69 0.61 0.51 0.57Nepal 90 0.73 0.21 0.20 0.30

Average Asian Countries -- 3.04 1.33 0.93 0.56

Developing Countries -- 4.40 1.68 1.79 0.71

OECD Countries -- 3.47 1.67 1.05 0.58

Sources: Per capita income taken from World Bank. World Tables, 1976. The

Johns Hopkins University Press, Baltimore, 1976.

Percentage expenditure figures for all countries except Pakistantaken from M. Zymelman. "Patterns of Educational Expenditures,"Staff Working Paper No. 246. World Bank, Washington, D.C.,November 1976.

Percentage expenditure figures for Pakistan calculated from figuresused by the Government Planning Commission for 1975.

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5.10 The conservative tendencies of many professional educators supportthe maintenance of academic standards which are no longer suited to the edu-cation and training needs of a poor but progressive society. Those educatorsare allied with upper and middle income parents to assure an increasing num-ber of university places for their children. This coalition makes it diffi-cult to close the gap between what the Government wants to do in educationand what it can accomplish.

5.11 Objectives. The 1972 National Education Policy 1/ established theobjectives of education in Pakistan and the draft Fifth Plan described theprograms and financial commitments needed to achieve them. Four centraleducational objectives, derived from the goals of increasing the rate ofeconomic growth and improving the distribution of income, were established.These were:

(i) Universal primary education would be the principal goal inthe Fifth Plan period.

(ii) Adequate provision would be made for expansion of technicaleducation to ensure that the technical manpower requirementsof the economy are fully met.

(iii) In all other spheres the emphasis would be on consolidationand improvement of quality of education to make it morepractical and meaningful.

(iv) The public sector expenditure on education would be increasedfrom 1.8% of GDP in 1976/77 to 3.0% in 1982/83. The achieve-ment of this target would involve an increase in developmentexpenditures on education at an average rate of 33% per annumand of recurrent expenditure on education at 15% per annum. 2/

5.12 These objectives are sound but several questions need to be consid-ered. Can the objectives be reached in six years? Are the assumptions onwhich they are based explicit and realistic? Will the education programoptimize the use of available resources?

Efficiency of Educational Investment

5.13 In order to achieve the objectives of the draft Fifth Plan, offi-cials predicted substantial improvement in the efficiency of past and futureeducational investments. Improved efficiency would inv,olve reduction ofstudent dropouts, better management of teacher training and.emloyment, andincreased participation of parents and teachers in school decisions. These

1/ Government of Pakistan, Ministry of Education, The Education Policy,1972-80 (Islamabad, 1972).

2/ Government of Pakistan, Planning Commission, Working Papers for FifthPlan (1977-83), Part II (Islamabad, October 1976), p. 206.

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changes could increase efficiency by reducing costs while maintaining atleast present levels of student achievement.

5.14 Primary Schooling. To achieve universal enrollment of boys aged5-9 in primary school by 1983 and of girls by 1987 would require, as thedraft Plan stated, a "drastic readjustment" of the existing education prior-ities. 1/ The share of total educational development expenditure for primaryeducation would increase from the present level of 14% to 30.5% over'the Planperiod. Recurrent primary expenditures would increase from 44% to 46%.

5.15 The planned expenditures would reverse the present trends forsecondary and higher education to expand more rapidly than primary education.A major question is the ability of the Government to resist the strong pres-sures by middle and. upper class parents to continue expansion of the post-primary levels. The draft Plan emphasized that "the interest groups affected... are likely to protest vigorously." 2/ Previous governments which alsogave high priority to primary education quickly succumbed to political pres-sures; funds originally allocated for primary school use were spent on post-primary education. The new primary school authority proposed by the Govern-ment is designed to prevent this recurring. Also essential to achieving thePlan would be complementary expenditures by the provinces, especially tofund recurrent costs.

5.16 Even if the Plan was fully funded by both Federal and ProvincialGovernments, and the education priorities approved, it is questionable ifthe schools could be built and students enrolled as targeted. It is doubtfulthat existing construction procedures permit the required rate of schoolexpansion. In 1976/77, 400 new primary schools were finished; the Planforecast 8,000 over six years, or 1,333 schools per year. One possibilitywould be to shift construction responsibilities from the public works depart-ments to a new construction department in the Department of Education. Asecond would be to share financial and construction responsibilities withthe communities which need the schools. The latter alternative has the advan-tage that communities would assume responsibility for the education of theirown children, thus building self-reliance. It would also lower the cost tothe Government.

5.17 The draft Plan assumed a zero rate of school dropouts by 1983, anassumption which is necessary to achieve the universal schooling targets. Atpresent, approximately 50% drop out before completing the fifth class. Onestudy has shown that children leave school for either family or school rea-sons. 3/ The families are too poor to afford to lose the labor of the child,

1/ Government of Pakistan, Planning Commission, Working Papers for FifthPlan (1977-83), Part II (Islamabad, October 1976), p. 109.

2/ Ibid., p. 211.

3/ Anwar Hussein and Nasim Shaukat, An Analytic Study of Dropout Factors inPrimary Schools of the Punjab, (Lahore: Institute of Education andResearch, December 1972).

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or cannot pay for the school uniform or supplies. Children are either sobored or mistreated by some teachers that they run away, and parents arepowerless to assist or change the teachers. The curriculum is not seen asrelevant or beneficial to future employment possibilities. The target ofzero dropouts would be more realistic if a program was proposed to deal withthese issues. The options include increasing supervision, selecting betterteachers, making learning more interesting and relevant, and initiating localaccountability by involving parents and local leaders.

5.18 What should be the qualitative targets for primary education? Whilethe draft Plan did not explore this issue, it assumed that some minimum stan-dards of school inputs and outcomes would be maintained with an investmentequal to Rs 160 per student for books and equipment. If these standards weremade explicit, the qualitative dimensions could be analyzed. Will the futureinputs be able to maintain or improve standards such as reading ability? Whatlevel of functional reading ability should be considered adequate for a sixthclass student? What are the traits such as cooperation, self-reliance andresponsibility, which the educators expect to inculcate in the children? In-formation on these issues would assist both in defining minimum standardsand in assuring that they are achieved.

5.19 Have all possibilities been explored to slow the increase in costper student for both development and recurrent items? From 1970 to 1975,recurrent costs in money terms tripled to reach Rs 30 per student, and theyare projected to double again by 1980. Development costs increased 2.7 timesduring the same period. Since recurrent items are 90% of the education bud-get, any reduction would effect considerable savings, provided quality didnot decline. The draft Plan assumed that an increase in real cost wouldyield an increase in the quality of school outcomes. This assumption needsto be made explicit, and a program developed to show how it would be achieved.

5.20 Some observers have maintained that a major constraint to increas-ing both the quality and quantity of rural primary education is the aggregatesupply of teachers. A major study of the teacher training institutions inKarachi by researchers at the University of Karachi funded by the World Banksuggests that, at least with regard to the Province of Sind, this is not thecase. 1/ The study found, for example, that 56% of the teachers were unem-ployed more than 13 months after graduation and that, even with such highlevels of unemployment, 70% of the graduates reported they would not considerteaching positions which are now vacant in rural areas. These findings havemajor implications for improving the admission procedures to select thosewho are willing and able to teach in rural areas. 2/

5.21 The study recommends reducing the number of teachers trained inKarachi while expanding rural facilities and requiring all students to take

1/ Robert E. Klitgaard, et al., "The Economics of Teacher Training"(Karachi: University of Karachi, January 1977).

2/ One reason why many graduates cannot teach outside Karachi is thatSindhi is required to teach in the rural areas, and most graduatesspeak only Urdu and English.

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a rural job upon graduation for a minimum number of years. Another approachto the problem currently being tried in North West Frontier Province and othercountries is to involve villagers in selecting Young people for teachertraining. It is hoped this will tend to encourage the individual's desireto serve the people in his or her village, rather than remain in or returnto the city at the first opportunity.

5.22 Technical Education and Training. An objective of the draft FifthPlan was to expand technical education to assure that perceived manpowerrequirements would be met. The Plan estimated that 12,000 engineers and68,000 technicians would be needed over the 1977-83 period, allowing formigration flows. 1/ Only modest expansion of facilities would be requiredto meet targets for new graduates since excess capacity now exists.

5.23 Two issues should be addressed to ensure that the trained manpoweris, in fact, sufficient, and that it is supplied in an efficient manner.First, is there a need to upgrade the quality of the graduates now emergingfrom the technical colleges and institutes? Second, has the Governmentexplored the most effective ways for ensuring that the graduates find thejobs for which they are trained? The draft Plan stated that "links betweentechnical education and industry would be strengthened." 2/ If strong linkscould be forged, both issues might be more easily resolved. A few collegesand institutes have taken the essential first step in creating advisorycouncils composed of representatives of management and labor. It has beenthe experience of other countries that these councils are effective onlywhen they play an important role in the planning, programming and budgetingof the training activities. If cooperation with management and labor can beeffectively achieved, the quality of training might be improved dramatically,with no increase in cost, and the unemployment of graduates reduced.

5.24 A third issue involves the question of the sufficiency of presentefforts in human resource planning. With the exception of the emigrationstudies in 1974, the last major planning efforts were made in the late 1960s.If the advisory councils at the technical institutes become effective, theirwork would virtually eliminate the need for the Government to organize short-term forecasting (3 to 18 months) of supply and demand. The councils couldgive accurate and rapid forecasts, for example, of the effect of emigrationon the local job market. Long-term planning studies, however, might examinethe supply and demand for a limited number of critical skills in some detailand explore the type and amount of work experience that employers desire.

5.25 Higher Education. The nation's colleges and universities absorb40% of capital expenditure on education and yet they appear, to an outside

1/ The sources for these data are: Government of Punjab, InvestmentAdvisory Centre of Pakistan, Survey of Availability of Pakistani Man-power for Foreign Employment (Karachi, September 1974), and Assessmentof Foreign Demand for Pakistani Manpower (Karachi, September 1974).

2/ Government of Pakistan, Planning Commission, Working Papers for FifthPlan (1977-83), Part II (Islamabad, October 1976), p. 213.

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observer, to comprise the level of education least responsive to nationaldevelopment needs. Recognizing the imbalance of the present level of fundingin favor of higher education, the draft Fifth Plan intended to curtail theexpansion of higher education while improving the quality of the existingcapacity. Successful implementation of the Plan program raises issues inthree areas: expansion of enrollments, allocation of expenditures, andimprovement in the quality of instruction.

5.26 The draft Fifth Plan assumed a slowing down in the present rate ofexpansion of higher education at the intermediate (11-12) and degree (13-14)levels (Table 18). The implementation of this proposal would require consid-erable will on the part of the Government, since (as already indicated) itwould be bound to meet strong opposition from powerful interest groups amongmiddle and upper income parents and( university staff.

Table 18: EXPANSION OF HIGHER EDUCATION

1972/73 1972-76 1976/77 1976-82 1982/83'000 annual growth '000 annual growth '000

Intermediate 137 5.5 170 4.4 220(11-12)

Degree 49 8.9 69 4.3 89(13-14)

Honors and 19 - 19 4.0 24Post-Graduate(13-17)

Source: Government of Pakistan, Planning Commission, Working Papers forFifth Plan (1977-83), Part II (Islamabad, October 1976), p. 213.

5.27 An analysis of flows of students from the tenth grade to the inter-mediate level highlights the nature and magnitude of the enrollment problemat the college and university levels. Over 170,000 students are currentlyenrolled in the two years of the intermediate level (grades 11 and 12). Theyrepresent 47% of the 362,000 enrolled in grade 10 in the previous two years.According to Planning Commission projections, the enrollment at the intermed-iate level in 1982/83 would be reduced to 37% of the grade 10 enrollment.This 10% reduction in the flow of students would mean a drastic cutback inthe rate of growth of opportunities for higher education.

5.28 In conjunction with the curtailment of expansion of enrollments,the draft Fifth Plan reduced the share of funds allocated to higher education.Capital expenditure would fall from the present level of 30% of total develop-ment expenditure on education to 15%, with capital and recurrent expenditurecombined falling from 22.4% to 15.2%. In the first four Five-Year Plans,

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the utilization of funds allocated for higher education exceeded by about2.5 times the utilization of funds allocated for primary education. Pastexperience indicates, therefore, that it would be difficult for the Govern-ment to decrease the proportion of funding for higher education to theextent proposed.

5.29 As an alternative to the construction of new colleges and univer-sities, existing capacity might be utilized better. A recent study suggeststhat the universities operate inefficiently at present. 1/ The study found,among other things, that the physical facilities and faculty and administra-tive resources of the University of Karachi were utilized almost exclusivelybetween 8:30 ip the morning and 1:30 in the afternoon; 30% of that semester'sclasses had been cancelled; one-fourth of the faculty was on leave while,in most cases, still drawing salary; the existing library.capacity was under-utilized; and, in summary, as analogous to a 40-hour work week, the universitywas operating on the average at about 50% capacity.

5.30 Similar evidence from other colleges and universities points toinefficient utilization of the physical and human capital invested in highereducation. This is even less acceptable when one considers that the Govern-ment pays for more than 95% of the cost of a university education.

5.31 One of the draft Fifth Plan's objectives was to improve the qualityof higher education. A Government-appointed commission of educators issueda series of three reports on the universities in 1975 which covered the tea-chers' problems, the students' problems, and education and research. 2/The reports concluded that the main problem faced by the universities wasfalling academic standards. The authors were struck with the contradictionbetween the Government's increasing reliance on education as a prime moverof development and the declining performance of the universities. Amongthe reasons cited for the falling standards were the lack of job prospectsfor students, which lessened motivation to study; insufficient pay for thefaculty; overcrowding of the facilities during the morning, combined withunderutilization during the afternoon; examinations which measure memoryskills rather than analytic skills; 3/ examiners who, because they are paid

1/ Robert E. Klitgaard, et al., "Can We Afford A Half-Time University?"Applied Economic Research Center, University of Karachi (December 1976).

2/ Government of Pakistan, University Grants Commission, Report of StudyGroup on University Teachers' Problems (M. Islam Sheikh, Chairman),Islamabad, July 1974; Report of Study Group on Student Problems inthe Universities (Imtiaz Ali, Chairman), (Islamabad, September 1975);Report of Study Group on Improvement of Education and Research inUniversities (Ahmed Mohiuddin, Chairman), Islamabad (July 1975).

3/ Examinations are limited to questions which have appeared in the previousfive years, and the students must only answer 50% of the questions. Asa result, most students ignore their studies, and rely on solved ques-tion papers of the preceding five years (UGC Report on Students,pp. 46-47).

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by the exam, may grade 30 final essay exams per hour, teachers who indis-criminately cancel classes and are unavailable to students after 1 p.m.; anda complete lack of linkages between the universities and industry.

5.32 Women in Education. The 1972 Education Policy stated one of itsobjectives as "equalizing access to education through provision of specialfacilities for women in all areas in general and the backward areas inparticular." 1/ The draft Fifth Plan contained a number of provisions toincrease educational opportunities for women, among which the target of uni-versal primary education for girls by 1986/87 was given high priority. Specialattention was also given to increasing education opportunities at the secon-dary level and for providing more women teachers in the schools.

5.33 Female enrollments, as a percentage of total enrollments, have beenrising at all levels of education since Independence, as shown in Figure 1.The most consistent rise has been at the primary level, where the femaleshare of total enrollment increased from 14% in 1947 to 28% in 1976. Thefemale percentage of middle school enrollment has increased from 9.5% to 20%,and from 12% to 17.5% at the high school level. However, the expansion ofeducational opportunity for females at the middle and high school levels hasbeen erratic. Female enrollments, as a percentage of total enrollments, werehighest at the end of the second Five Year Plan in the period 1963 to 1965,reaching 21% of the total in middle schools and 25% in high schools. But fromthat period, the participation of females dropped steadily and only began torise again in 1975.

5.34 Female education is important both because it increases the abilityof women to become economically productive members of the society, thus rais-ing their social status, and because it tends to be associated with lowerfertility, as discussed in Chapter III. The Government's commitment toincrease the lot of the poor and to reduce the rate of growth of populationcan therefore be greatly helped by a more consistent effort to provide educa-tional opportunities to women.

5.35 Retention ratios at the primary level show that females drop outfaster than males, so that only 22% of females who enter primary school goon to middle school, compared to 41% of males. The dropout problem forfemales is especially acute between the first and second grades (only 64%of those enrolled in first grade enter second grade) and between fifth andsixth grades (only 57% of those who enter fifth grade enroll in middle school).However, the retention ratios also indicate that a girl who does enroll inmiddle school has about the same probability of finishing high school as amale. The data suggest that females have a much more difficult time inschool than males, but that those females who do finish primary school andenroll in middle school either have special outside advantages or have over-come their disadvantages.

1/ Government of Pakistan, Ministry of Education, The Education Policy,1972-80 (Islamabad, 1972).

- 0 '3' 0 en 0 ~~~~~~~~~~~~~.JI~t Ow(c e O _ _ _ _ _ _ _ _ _ _

2

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.- L -------------~~~~~~~----------- ----- C-- -1--------- -------- N---------

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5.36 In summary, educational opportunity for females is greater nowthan in 1947 at all levels of education. The primary level, especially, hasshown a significant rise in female participation. At middle and high schoollevels, the expansion of educational opportunity for women, as measured bytheir percentage of total enrollments, declined from about 1963 onward. Onlyin the last two years has the trend been reversed and it is still too earlyto tell if the reversal is a permanent change. The problem of female drop-outs will continue to hinder efforts to increase educational opportunitiesfor women at all levels. As long as the cumulative effect of dropouts issuch that only 10% of the females who enroll in grade one enter grade 10,expansion of the role of women in Pakistan society will be limited.

5.37 Curriculum Reform. An important objective of the draft Fifth Planwas to "improve the quality of education to make it more practical and mean-ingful." For secondary education this meant the "rapid introduction of agro-technical courses throughout the country." 1/ At the higher level the goalwas to shift "enrollment from arts to science and technical subjects." 2/The Plan also proposed to carry out a "systematic and integrated reform ofcurricula and examinations and to check malpractices and corruption."

5.38 Pakistan educators believe that formal education can be made morepractical by introducing agrotechnical subjects into the curriculum for the6th through 10th classes. This has already been started with the 6th class.Do parents and students share this perception? If they do not, can thecourses be successfully introduced? Will final examinations, for example,be given in all these courses, and will the grades contribute to a student'sclass rank, providing at least a minimum incentive? Will the opportunityto teach be given to capable community members--including draftsmen, farmers,nurses and extension agents? Have the experiences of other countries whichhave tried the same approach been studied to understand why they have usuallyfailed?

5.39 Based on the experiences of other countries, a major element inthe success of a program to make education more relevant to daily needs appearsto be an increase of the responsibility of the parents and community leadersin planning and managing school activities. The ineffectiveness of the sc.hoolcouncils which exist now at the secondary level appears to be related to alack of authority. Some provincial officials are considering startingcouncils for primary schools and giving them a fairly wide range of respon-sibilities. These would include the construction and maintenance of theschools, as well as the selection of villagers to be sent for teacher train-ing. The councils would also report to district supervisors on teacherabsenteeism or mistreatment of students. This would help to provide thelocal accountability which is presently lacking.

1/ Government of Pakistan, Planning Commission, Working Papers for FifthPlan (1977-83), Part II (Islamabad, 1976), p. 212.

2/ Ibid., p. 214.

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5.40 The purpose of higher education is to provide adequate numbers ofhighly skilled workers for the economy who, at the same time, embody thetraits of responsible citizens and parents. Major studies carried out bythe University Grants Commission suggest that the mechanisms for achievingthis purpose appear to be lacking. 1/ Making education more practical hasmeant thus far restricting the percentage of arts students and expanding thenumber of those taking science. This assumes that the present science curri-culum is suitable to employer needs. The university reforms assume that theuniversity authorities will find a politically acceptable mechanism for re-stricting student freedom. Careful study of these two assumptions mightassist in achieving Plan goals. Some educators have suggested that potentialemployers be consulted continuously with regard to both the kind of trainingdesired in new employees and the number and types of openings anticipated overthe next few years. While this might pose a threat to faculty who do not wishto modify their courses, it could prove an effective mechanism for providingessential information on the labor market.

5.41 Until higher education is brought more closely into contact withthe realities of the workplace, it is unlikely that even the reforms mentionedabove will make it more practical. Since the mechanisms for achieving ade-quate contact between university and workplace do not yet seem to exist, someauthorities are discussing two additional possible reforms. The first wouldrequire that all students leave school after 10th class for at least twoyears of work before applying for higher studies. The second would requirethat admission to higher studies be granted only to those students who coulddemonstrate, while at work, that they are hard workers, selfless and dedi-cated to the goals of the society. Both these reforms should have the effectof bringing the problems of the workplace into the classroom, thus makingeducation more practical. A high level of motivation among the students whodo finally reach university should also result.

5.42 Examinations. The examination system shapes the direction andquality of education in Pakistan. A decentralized group of examination boardswrite and administer the yearly examinations. Each province has at leastone board and some have several. The examinations form a series of obstaclesin the path of each student and result in paring down the number of studentsthat continue to higher levels of education. The grades obtained on thematric exam at the end of secondary school greatly affect employment oppor-tunities. The intermediate examination taken at the end of the first twoyears of college must be passed to secure a Government position.

5.43 The formal external examinations are designed to maintain academicstandards in a system where the quality of teaching varies widely. The

1/ Cf. the following Study Group Reports of the Government of Pakistan'sUniversity Grants Commission: University Teachers Problems (Islamabad,July 1974); Student Problems in the Universities (Islamabad, September1975); and Improvement of Education and Research in Universities(Islamabad, July 1975).

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rigidity of the system has in fact led to serious breaches in standards.The examinations have become more important than the actual learning process.The tests can be passed solely by rote. Because internal evaluations haveno value, the students lack incentive to perform well on a daily basis, anddo not feel strong pressure to attend lectures and participate in discussiongroups. Education appears more a matter of short-term memorization of manyfacts than an attempt to master a given subject. In the absence of otheruniform evaluation systems, the grades received on the external examinationshave been taken as the most likely indicator of future success in school.

5.44 A recent study, 1/ however, suggests that past performance on exam-inations is not a good predictor of future performance in school. The studyfound that for a sample of over 2,800 graduates of Karachi University in 1971,students' intermediate marks and matric marks were only weakly correlated withfinal performance marks. The report concluded that if the goal is to admitstudents who will do well on the final performance examinations, performanceon prior examinations is not a good criterion for admission. The report urgedthe adoption of additional measures, such as achievement tests in relevantsubjects, aptitude tests, and interviews.

5.45 Similar recommendations have been made before. Since the Commissionon National Education issued its report in 1959, at least nine commissions haveaddressed the problems of the examination system. The commissions have recom-mended the institution of internal evaluation by teachers and the maintenanceof cumulative records in order to shift emphasis away from external examina-tions. As a means of improving the examinations, the commissions have urgeda change away from recent essay questions that measure the ability to recitescores of facts, and toward objective questions that measure reasoning abilityand understanding of a subject. A major program is now underway to developobjective tests.

5.46 Reforming the examination system per se will not solve the prob-lems of the education system, if indeed the institution of a meaningfulinternal evaluation is even possible, given the present emphasis of thesystem on the few that finish and get high-ranking jobs. But improvementsin the quality of the examinations, accompanied by similar changes in thecurriculum, are a necessary condition for improvement of Pakistan education.

Economic Impact of Educational Investment

5.47 Given the needs of the country, it is imperative that the Govern-ment try to obtain the maximum possible social return on its investments.At present, there is a great deal of unemployment among educated people.This appears to be one of the reasons for the brain drain. At the same time,the system as it is operating does not appear to be contributing effectivelyeither to economic growth or to equity. This calls for an increased role for

1/ Robert E. Klitgaard, "Student Merit and Admissions Policy for PharmacySchool," Applied Economics Research Centre, University of Karachi(September 1975).

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planning and research to insure that the educational system serves the basicobjectives of the economy.

5.48 Unemployment of the Educated. One of the most serious, mostdiscussed and least changed of the economic and educational problems ofthe last 10 years is that of the educated unemployed. In 1973, 2.5 millionpersons or 12.8% of the labor force were unemployed. Over 803,000, or oneout of every three-af-the- unemployed,--h-ad--at-least--finished primary school. 1/Over 319,000 of the unemployed had matric (lOth grade) certificates or better.More than 42,000 had university degrees, equal to two years of graduates fromPakistan's eight universities.

5.49 Our definition of educated unemployed includes three categories:the "more educated" with matric and above; the "less educated" with primarycertificates but less than matric; and "literate only" with or without formalschooling. Table 19 emphasizes that primary school dropouts who comprise the"literate only" category are not the major dimension of educated unemployment.They make up only 23% of the total, although they have the highest unemploy-ment rate. The largest number of educated unemployed are persons with primaryschool certificates but less than matric, followed by those with matric andabove.

5.50 The length of unemployment for the matric and diploma holders isquite long. A national survey of middle level technicians who had been outof school 5 to 10 years showed that 24.4% were unemployed in 1970. 2/ Anotherstudy in 1970, only of graduates of Lahore Polytechnic, reveals that 44% ofits graduates had been unemployed more than a year. 3/ A study in NorthWest Frontier Province in 1972 showed that I to 2 years after graduation,64% of the matric graduates and 50% of the intermediate graduates neitherhad jobs nor continued with school. 4/

1/ Government of Pakistan, Housing, Education and Demographic Survey (1972).

2/ Government of Pakistan, Ministry of Labour, National Manpower Council,"Technical Manpower Survey (1970)," as cited in A.A. Anwar, Problemsof Unemployment of the Educated Manpower, The Board of Economic Inquiry(Punjab, 1973), p. 9.

3/ E. Van Lent, "Lahore Polytechnic Graduates Employment Survey," FourthPlan Paper No. 15, March 1971, as cited in A.A. Anwar, op cit., p. 9.

4/ Board of Economic Inquiry, North West Frontier Province, University ofPeshawar, "Unemployment among the Educated Manpower in North WestFrontier Province," 1972, as cited in A.A. Anwar, op cit., p. 12.

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Table 19: LABOR FORCE AND UNEMPLOYMENT ACCORDINGTO LEVEL OF EDUCATION /a

(thousands)

PercentageTotal Labor Force Unemployed by Unemployed byby Educational Educational Educational

Level Level Level

More Educated 1,901 320 16.8Less Educated 3,123 485 15.5Literate Only 846 263 31.1

Total Literates 5,871 1,068 18.2Total Illiterates 14,022 1,478 10.5Total Labor Force 19,893 2,546 12.8

/a More educated: Those with matric and above.Less educated: Those with primary certificates but less than matric.Literate only: Those who are literate only, regardless of the level of

formal education.

Source: Housing, Education, and Demographic Survey, 1972, Table 23.

5.51 University graduates fared little better based on a study in 1972. 1/Interviews were conducted with graduates who had completed study at the threePunjab universities 3 to 4 years earlier. 47% were unemployed. Only 15% ofthese had ever had a job, and only 2% said they were holding part time jobs.Another study found that 16% of the graduates of the Agricultural Universitywere unemployed 2 to 8 years after leaving university. 2/ Only 66% of thosewho were working had jobs connected with agriculture.

5.52 Partial evidence suggests that the surplus is growing in mostskill areas. The projections in Table 20 indicate a net surplus of 246,000with matric and above in 1975, reaching 657,000 by 1985. The economy cannotabsorb either the number or the type of school leavers with certificates atthe matric level and above. An increasing amount of resources is, therefore,being wasted in training at this level.

1/ A.A. Anwar, op cit., pp. 32 and 48.

2/ Agricultural University, Faisalabad and the National Manpower Council,Karachi, "Survey on Technical Manpower," 1970,.as cited in A.A. Anwar,op cit., p. 171.

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Table 20: STOCK OF SURPLUS EDUCATED MANPOWER (MATRICAND ABOVE), 1965-90

(in thousands)

Years Supply Demand Surplus

1965 749 701 481970 1,065 962 1041975 1,514 1,268 2461980 2,133 1,709 4241985 2,948 2,292 6571990 3,996 3,058 938

Sources: Saudagar, "Problems of Educated Unemployed," Pakistan Labor Journal,February 1975, and the 1972 Housing, Education, and DemographicSurvey, Table 23. Figures for 1975 and thereafter are estimates.

5.53 The Brain Drain. Pakistan now faces two kinds of emigration oflabor: the emigration of professionals--doctors, engineers, and scientists--and the emigration of skilled and semi-skilled workers. The emigration ofprofessionals has gone on for a number of years, mainly to the developedcountries, such as Great Britain, Canada, and the United States. The emigra-tion to the Middle East of skilled and semi-skilled labor is a more recentphenomenon, resulting from the rapid economic expansion of that region since1973. These migration patterns raise important policy issues relevant to theeducation of both the professional and skilled labor groups.

5.54 The emigration of both types of labor has ambiguous effects on thePakistan economy. Analysis of the effects is made doubly difficult by thelack of data on the numbers that leave the country, as well as the numbersthat return. The analysis of the net effect of emigration has often centeredon the trade-offs between the effects of the loss of manpower and the gainin remittances sent back by the emigrants. Table 21 shows the number ofPakistanis selected for overseas public and private sector employment throughthe Bureau of Emigration and Overseas Employment during a five year periodended in June 1976. The table also shows workers' remittances during thatperiod. Total emigration over the five years was probably more than twicethe official emigration. Workers' remittances from abroad have increaseddramatically, to the point where they are now the largest source of foreignexchange for Pakistan.

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Table 21: WORKERS' REMITTANCES (1971-76) AND NUMBEROF EMIGRANTS SELECTED BY THE BUREAU OF

EMIGRATION AND OVERSEAS EMPLOYMENT

AmountFiscal Years (Million US$) Emigrants

1971 57 3,5341972 96 1,5301973 146 12,3001974 151 16,3281975 230 23,0771976 320 15,459 (Jan.-June)

Sources: World Bank, "Pakistan: Recent Trends and Devel-opment Prospects," Report No. 1023-PAK, WorldBank, Washington, D.C., March 1, 1976.

Irfanul Haque, "The Question of Brain Drain WithSpecial Reference to Pakistan," Quarterly EconomicJournal (April-June, 1976), pp. 31-36.

Figures supplied by the Bureau of Emigration andOverseas Employment, November 1976.

Emigration has two separate effects on Pakistan. The most discussed effectis the loss of manpower. A second effect is the over-expansion of the upper

levels of education. The possibility of migrating t,o a foreign country with

a higher level of income tends to increase salaries at home. The increased

wage rates create a political demand for education and over-expansion of the

education system. Thus, more graduates are produced than can be absorbed,resulting in-open unemployment. 1/

5.55 Setting aside, momentarily, the effects of over-expansion of the

upper levels of the education system, does the actual emigration of profes-

sional and skilled labor hurt Pakistan? The individual does not bear the

full cost of his or her education. Thus, as Bhagwati and Hamada point out, 2/

1/ For further analyses of this effect, see Bhagwati and Dellalfar, "The

Brain Drain and Income Taxation: The U.S.," in J.N. Bhagwati and M.

Partington (eds.). Taxing the Brain Drain: A Proposal (Amsterdam-NewYork-Oxford, North Holland Publishing Company, 1976). Also see Harris

and Todaro, "Migration, Unemployment and Development: A Two-SectorAnalysis," American Economic Review, Vol. 60, pp. 126-142.

2/ J. Bhagwati and K. Hamada, "The Brain Drain, International Integrationof Markets for Professionals and Unemployment." Journal of Development

Economics, Vol. 1, No. 1 (June 1974), p. 21.

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if it is assumed that the Government would have taxed a worker (had he orshe not emigrated) to recover the return on the Government's investment,the worker's emigration does deprive those left behind of this returnon the Government's investment and thus worsens their welfare.

5.56 Table 22 illustrates the findings of a Government study to deter-mine the per student costs of education at different levels.

Table 22: COSTS OF EDUCATION PER STUDENT ACCORDING TO LEVEL(Rupees)

Pupil-BorneRecurrent Costs Social

Government-Borne Foregone RecurrentEducation Level Recurrent Costs Ia Supplies Earnings Cost

Primary (1-5) 1,050 150 2,280 2,480Middle (6-8) 945 120 3,192 4,257High (9-10) 1,566 96 2,888 4,550Intermediate (11-12) 4,810 740 3,496 9,046Upper (13-14) 5,604 788 4,104 10,496University (15-16) 17,636 818 4,864 23,318Engineering College

(13-16) 35,272 1,636 9,728 46,636Medical (13-17) 44,090 2,045 12,160 58,295

/a Double shifting in schools is assumed, with walls between boys andgirls in the same room. At the intermediate level and above, a govern-ment subsidy of Rs 218/year for student housing is assumed. Costsinclude salaries and annual amortization on capital expenditures.

Source: Government of Pakistan, Ministry of Education, Bureau of EducationPlanning and Management, Pakistan Education 1974: A Sector Assess-ment (Islamabad, October 1974).

The table illustrates the dramatic increases in the cost of education as theeducation level rises, as well as the substantial proportion of educationexpenses borne by the Government. Using the figures in the table, the invest-ment made by the Government which is lost when the person emigrates can becalculated. If the Government can recover the costs of education, and ifit is assumed that more individuals can be trained to replace those withneeded skills lost through emigration, it is not clear that emigration isbad for Pakistan.

- 65 -

Table 23: TOTAL GOVERNMENT COST TO EDUCATE

Government-Borne RecurrentCategory Costs ('OOOs of Rupees)

Engineers 44Physicians 52University Graduates 32College Graduates 14Skilled and Semi-skilled Workers 4

Source: Table 22.

The data suggest that professionals are likely to emigrate with their familiesand consequently are unlikely to send back much in the form of remittances.They are also unlikely to return to Pakistan. The training of doctors is anotable case in point. During 1973 and 1974 the number of registered doctorsin Pakistan increased by 1,405 while the number of doctors selected for for-eign employment through the Bureau of Emigration was 508, or roughly 36%. 1/Unofficial emigration may have been equal to the official emigration, whichwould raise the percentage of emigrating newly-trained doctors to 72%. Forprofessionals such as doctors, investment in education seems to be a losingproposition for the Pakistan Government and is, therefore, hurting the country.

5.57 Skilled and semi-skilled emigrants are markedly different than pro-fessionals. Most emigrants in this category go to the Middle East on con-tracts. The Government expends relatively little to train them, and sincethey leave their families behind, their remittances are quite high. Althoughtheir emigration has caused some shortages of skilled labor, their contractsare temporary, so the economy faces no permanent loss of their manpower.Indeed, to the extent that they gain additional expertise during their periodin the Middle East, they may actually contribute more to the economy whenthey return. Given the low cost of training skilled and semi-skilled man-power, it makes sense to encourage the temporary emigration of these workers,especially if the Government makes plans to absorb them when they return.If the emigrants to the Middle East turn out to be permanent emigrants, theeffects are more ambiguous.

5.58 Economic Growth and Income Distribution. To what extent does edu-cation in Pakistan contribute to higher productivity and economic growth?Although investment in education may have promoted economic growth, the impacthas probably been less than the planners and educators believe. Schoolingshapes both cognitive skills and behavioral traits needed in the workplace.The data suggest that many of the skills taught in school are more useful inpassing the examinations than in performing work tasks afterwards; that ade-quate levels of reading comprehension may not be achieved by primary school

1/ Irfanul Haque, "The Question of Brain Drain With Special Reference toPakistan," Quarterly Economic Journal (April-June 1976).

- 66 -

graduates; that wage differentials based on schooling are much wider thanthey need to be to provide sufficient incentives; and that the system has astrong political bias toward providing easy access to high paying jobs tothe children of the elite, while maintaining the false impression that theselection was fair.

5.59 A major argument on the role of education in promoting economicgrowth is that if farmers, for example, are taught to read and calculate,this would increase their productivity and income. Reading, however, isnot necessary to increase productivity--as thousands of illiterate farmersin Punjab demonstrated in the late 1960s. Furthermore, once literate,the farmer must have materials to read that will contribute both to increas-ing yields and to assuring continuing literacy. Finally, as research onadaptation of new husbandry and technology has shown, and as extensionagencies have maintained, reading about the innovation is neither a necessarynor sufficient condition to adopting it. It is true that the studies insome countries show that farmers who have completed primary schooling havehigher yields than those who have not. Unfortunately, however, most studieshave not been formulated in a manner conducive to contributing much to policydecisions. For example, they do not measure the motivation or intellectualability of those who do not attend school; thus the difference in yieldsbetween farmers with schooling and those without may be motivation and ability,not schooling. Second, in some cases, farmers with schooling have beenfound to have forgotten how to read, but their productivity is still betterthan those who have not gone to school. What is it about their experiencein school that makes the difference? Is it related to behaviorial factorssuch as discipline, cooperation and hard work? Studies thus far do not pro-vide adequate answers to these and related questions. 1/

5.60 The expansion of "free education" has been seen by some as aneffective way to narrow the gap in income between the poorest and richest20% of a country's population. But the practice in Pakistan, as in manyother countries, is that the poor do not have an equal chance at eitherattending school or obtaining certificates. For example, children fromricher families benefit from free university education that costs the tax-payer Rs 8,800 per student per year compared to Rs 210 per student at theprimary level. 2/ The proportion of poor who can take advantage of thatsubsidy is comparatively small. The composition of the student body atthe university level illustrates the difference of educational opportunitybetween the poorest and the richest. A study conducted at the University

1/ For an approach that begins to deal with some of the limitations ofthe earlier studies, see Dean Jamison and Susan Cochrane. "EducationalResearch in Nepal." World Bank, Washington, D.C. (January 1977).

2/ See Table 24. Capital costs for each new student are approximatelyRs 100,000 at the university level as opposed to Rs 1,000 at the primarylevel (draft Fifth Plan, p. 222).

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of Karachi found that approximately 60% of the students at the universityare from the middle and upper income families, which comprise about 20%of the total population. Students with fathers who have a university degreeare over-represented compared to the general population. This substantiatesthe hypothesis that investment in education still contributes to the widen-ing of the gap between rich and poor.

5.61 The Government has taken steps to make education less regressive,mainly through a scholarship program which totals Rs 60 million per year.Only a small percentage of that support, however, goes to the poor. Onethousand President's Scholarships are distributed to students with firstdivision matric results (tenth class) whose parents earn less than Rs 500per month. The original guidelines of the program, established in 1973,benefited students with parents earning less than Rs 200. There were so fewfirst division students, however, at this income level that the minimum wasraised to Rs 500. Thus, the program does not help the poorest families sincethe poorest 60% of the population, or 7 million families, earn less thanRs 200 per month. The President's scholarships have a total value of approxi-mately Rs 20 million, or 30% of the total scholarship funds. 70% of thescholarships are awarded on the basis of class rank, not parental income, andgo to upper income families. Thus, it is doubtful that even the scholarshipprogram has a net progressive effect on income distribution.

5.62 In sum, while the Government has attempted to use education topromote equity, the reverse is happening. The effect on yields of the formaLeducation of farmers as separate from other inputs is so small that it is notlikely to contribute to a narrowing of the distribution of income betweenrich and poor. In fact, because of the strength of other factors such asthe large expenditure on the education of upper income children, regressivetaxation and unfavorable terms of trade for farmers, education is wideningthe gap between rich and poor. Reforms are needed both to make educationmore relevant to the needs of the country and to shift its benefits fromthe richer to the poorer groups.

Conclusions

5.63 The draft Fifth Plan provided for a radical shift of investmentpriorities to primary education, concomitantly calling for reduction in therate of expansion of secondary and higher education. To ensure that theprovinces will not transfer funds earmarked for primary to other levels,national legislation was being prepared to make the funds nontransferable.Implementation of the Plan ideas is a necessary, but not sufficient, condi-tion for the redistribution of educational opportunity from the upper tothe lower classes.

5.64 Making the educational system more relevant to the needs of bothlow income groups and employers is receiving much needed priority afteryears of emphasis on the expansion of the number of school places. Becauseefforts to deal with this problem have only started, actual programs havenot yet been developed. Some Government planners, however, realize that,

7 68 -

to achieve relevance, it is necessary to increase participation by students,parents, employers, and other beneficiaries of education in the planning andmanagement of education and training.

5.65 Several years ago .ducation decisions were decentralized to theprovincial level; now an increasing number will be formulated on the districtand community levels. As mentioned earlier, some,provinces are alreadytransferring authority to make decisions on'te'cher transfers and othermatters to the districts, and other provinces are asking the communities toselect individuals for teacher training to assure local accountability forwhat happens in the classroom. School cotuncils of parents and leaders arebeing established to manage primary schools. Some colleges and universitiesare establishing tripartite advisory boards (labor, management and government)to ensure that training is relevant to job openings and that the graduateswill be ensured jobs. These are important first steps in making educationand training better adapted to community and employer needs. However, theseexperiments need to be carefully evaluated before being used in the prepara-tion of a comprehensive strategy for reform of educational management.

APPENDIX 1- 69 - Page 1

DERIVATION OF THE POPULATION PROJECTIONS

1. The four population projections for Pakistan referred to in thetext were derived from a base year population in 1972 and assumptions concern-ing mortality, fertility, rural-urban transition, and labor force composition.The following section will discuss the derivation of each of the populationprojection parameters, including the actual figures used for each projection.

(a) Base Population

2. The base population was derived from the Big Count of the 1972Census, 1/ the Census Evaluation Survey (CES), 2/ and the Housing, Education,and Demographic (HED) 3/ Survey of 1973. The HED survey gave the age and sexbreakdown for rural and urban areas. The CES reported the percentage of totalunderenumeration in the 1972 Census Big Count and the percentage of under-enumeration for rural and urban areas and for children.

(i) Total Population. The population census of September 16-30,1972 gave a figure of 64.9 million for the population ofPakistan. According to the CES, the census count was under-enumerated by 6.3%. Therefore, the corrected total for the1972 census was 69.0 million. That total, in turn, wascorrected back from September 23 to July 1, assuming a rateof-natural increase of 3.5%. The resulting figure of 68.4million was used as the base year total population.

(ii) Distribution of the Base Population. The age-sex and urban-rural distributions of the population are based on the dis-tribution found by the HED Survey (see Table A-1). Thecorrections to the distribution will be explained in severalsteps:

1/ Government of Pakistan, Census of Population, 1972.

2/ Government of Pakistan, Ministry of Finance, Planning and Development,Statistical Division. Census Evaluation Survey: Population Census,1972. 1974.

3/ Government of Pakistan, Housing, Education and Demographic Survey,1973.

APPENDIX 1

- 70 - Page 2

Table A-1: POPULATION DISTRIBUTION ACCORDING TO THE HED SURVEY ('000s)

Urban Rural Total

Age Males Females Males Females Males Females

0- 4 1,161 1,147 2,987 3,065 4,148 4,212

5- 9 1,350 1,228 3,803 3,389 5,152 4,616

10-14 1,275 1,083 3,216 2,471 4,491 3,554

15-17 ,932 760 2,183 1,630 3,115 2,390

20-24 729 593 1,598 1,418 2,327 2,010

25-29 626 564 1,567 1,480 2,193 2,044

30-34 519 465 1,341 1,262 1,860 1,727

35-39 486 439 1,191 1,151 1,677 1,590

40-44 441 354 1,152 993 1,593 1,348

45-49 377 286 906 852 1,283 1,149

50-54 341 229 1,011 745 1,352 974

55-59 170 147 475 491 645 638

60-64 235 163 838 534 1,073 697

65-69 106 82 323 255 429 337

70-74 116 76 428 250 544 326

75+ 151 97 477 288 628 385

Sub-

Totals 9,017 7,725 23,494 20,273 32,511 27,998

Totals 16,742 43,767 60,510

Source: Housing, Education, and Demographic Survey, 1973.

1. The total figures for males and females by rural

and urban were inflated according to the CES cor-

rection factors:

HED CES Correc- CES Addition

Results tion Factor to Population

Urban males 9,017,242 1.080 722,000

Urban females 7,725,292 1.086 665,000

Rural males 23,493,948 1.054 1,269,000

Rural females 20,273,053 1.058 1,176,000

2. The total population after the correction was 64.3

million. In order to make the total population agree

with the CES corrected 1972 census figure of 68.4

million (see (i) above), each age cohort was in-

creased by 6.35%.

- 71 - APPENDIX 1Page 3

3. In the base population, the age cohorts 0-4 and 5-9were underenumerated, so an additional correction wasmade to the age distribution. The total population of1972 was projected backward, using a rate of naturalincrease of 3.5%, to the end of 1965 and the end of1970. The population at the end of 1965 was the medianpopulation for the period 1962-67, while the populationat the end of 1970 was the median population for 1967-72.A crude birth rate of 48 per thousand was applied to thepopulations to determine the number of births for 1965and 1970; the births were multiplied by 5.to arrive atan estimate of total births for the two five-year periods.By assuming a sex ratio at birth of 1.07, the births weredivided into male and female cohorts. A life expectancyat birth of 50.2 years for males and 48.4 years for femaleswas used to determine survival ratios for males and femalesand therefore estimate the populations of the 0-4 and 5-9age cohorts in 1972.

4. The calculated populations for age cohorts 0-4 and 5-9were then used in the age distributions with the otherage cohorts proportionally reduced to keep the totalpopulation at 68.4 million. The resulting age distri-bution (Table A-2) was used as the base population forthe four population projections.

- 72 - APPENDIX 1Page 4

Table A-2: BASE POPULATION (JULY 1, 1972) USED FOR THE POPULATION PROJECTIONS

Urban ('000) Rural ('000) Total ('000)

Age Males Females Males Females Males Females

0- 4 1,871 1,674 4,815 4,472 6,686 6,146

5- 9 1,404 1,290 3,955 3,560 5,359 4,850

10-14 1,388 1,206 3,381 2,639 4,769 3,845

15-19 1,014 846 2,294 1,740 3,308 2,586

20-24 794 660 1,677 1,516 2,471 2,176

25-29 685 628 1,644 1,583 2,329 2,211

30-34 565 518 1,410 1,350 1,975 1,868

35-39 529 490 1,252 1,230 1,781 1,720

40-44 480 394 1,212 1,064 1,692 1,458

45-49 410 330 952 914 1,362 1,244

50-54 371 255 1,065 799 1,436 1,054

55-59 185 165 500 525 685 690

60-64 256 182 883 572 1,139 754

65-69 115 92 341 272 456 364

70+ 290 193 955 576 1,245 769

Sub-Totals 10,357 8,923 26,336 22,812 36,693 31,735

Totals 19,280 49,148 68,428

(b) Mortality

3. The mortality assumptions utilize the West Model for mortality.

Life expectancy at birth was based on a two-year average of the 1968 and 1971

Population Growth Survey, 1/ adjusted for the base year figures as follows:

1/ Naseem Iqbal Farooqui and Iqbal Alam, "Provisional Abridged Life Tables

for Urban and Rural Areas in Pakistan, Based on PGS, 1968 and 1971."

The Pakistan Development Review, Vol. XIII, No. 3, Autumn 1974, pp.

335-352.

- 73 - APPENDIX 1Page 5

Urban RuralMales Females Males Females

Population Growth Survey 54.5 53.6 52.4 51.9Two-Year Adjustment +1.2 +1.2 +1.2 +1.2Base Year (1972) Figures 55.7 54.8 53.6 53.1

4. For the projections, the rates of increase of expectation of lifeat birth were assumed to be a function of the actual level of expectation oflife, as follows: 1/

Expectation of Life Annual Increase of Expectationat Birth (Years) of Life of Birth (Years)

Male Female

50-59.9 .6 .760-64.9 .4 .565-69.9 .2 .370+ .1 .2

5. Thus, urban males began with a life expectancy of 55.7, which wasincreased at .6 years per year for 8 years, .4 years per year for 12 years,.2 years per year for 24 years, and .1 year per year for the remainder ofthe projection period.

6. All four projections used the same mortality assumptions.

(c) Fertility

7. The base year age-specific fertility rates utilized the nationalfigures of the Population Growth Experiment (Chandra-Deming estimate). Ruraland urban rates were derived from differentials in fertility as reported inthe 1971 Population Growth Survey.

1/ K.C. Zachariah and R. Cuca, "Population Projections for Bank MemberCountries 1970-2000", World Bank, Washington, DC., 1973.

- 74 - APPENDIX 1Page 6

Table A-3: BASE YEAR AGE-SPECIFIC FERTILITY RATES

PGE PGS 1971(Chandra-Deming) Rural/Urban Rural Urban

Age Group Adjustment Fertility Ratio ASFR ASFR

15-19 .130 1.4255 .144 .10120-24 .303 1.0386 .306 .29525-29 .373 0.9559 .368 .385

30-34 .353 1.0268 .355 .34635-39 .250 1.1771 .261 .22240-44 .114 1.5392 .126 .08245-49 .067 2.3902 .079 .033

Total FertilityRate 7.95 8.195 7.32

8. The four projections used different assumptions to change the ruraland urban total fertility rates over the projection period. The age-specificcomposition of fertility was kept constant for all projections.

9. In projection one, the total fertility rates for urban and ruralareas were kept constant. In projection two, fertility for the urban popula-tion was held constant for the first 5 years, and then decreased at 1% peryear for 17 years, 2% per year for 9 years, 3% per year for 8 years, and 2%per year for 11 years. The rural fertility rate was held constant of 5 yearsand then reduced at a yearly rate of 1% for 28 years, 2% for 9 years, and 3%for 8 years.

10. In projection three, fertility was held constant for the first 5years for both rural and urban populations, then reduced at 0.4 points peryear for 13 years (to replacement level for the urban population) and heldconstant for the remainder of the period. Projection four held fertilityconstant for the first 5 years, and in the sixth year reduced the total fer-tility rate to 2.8 in urban areas and 2.86 in rural areas. The total fer-tility rates in both urban and rural areas were then linearly reduced toreplacement level in the last year of the projection period.

11. Table A-4 shows the specific fertility assumptions.

- 75 - APPENDIX 1Page 7

Table A-4: TOTAL FEKTHA.l.tTY RATES USED IN PROJECTIONS

1972 1977 1982 1987 1992 1997 2002 2007 2012 2017 2021

Series 1

Rural TFR 8.195 8.195 8.195 8.195 8.195 8.195 8.195 8.195 8.195 8.195 8.195Urban TFR 7.320 7.320 7.320 7.320. 7.320 7.320 7.320 7.320 7.320 7.320 7.320Total TFR 7.940 7.900 7.874 7.845 7.821 7.791 7.767 7.746 7.731 7.712 7.699

Series 2

Rural TFR 8.195 8.113 7.715 7.337 6.978 6.636 6.311 5.821 5.262 4.565 4.042Urban TFR 7.320 7.247 6.892 6.554 6.233 5.691 5.145 4.418 3.872 3.500 3.229Total TFR 7.940 7.821 7.422 7.042 6.685 6.241 5.801 5.185 4.615 4.054 3.644

Series 3

Rural TFR 8.195 7.798 5.812 3.826 3.032 3.032 3.032 3.032 3.032 3.032 3.032Urban TFR 7.320 6.917 4.904 2.891 2.196 2.196 2.196 2.196 2.196 2.196 2.196Total TFR 7.940 7.501 5.498 3.496 2.731 2.720 '2.712 2.706 2.701 2.691 2.681

Series 4

Rural TFR 8.195 2.868 2.794 2.719 2.645 2.570 2.496 2.421 2.347 2.272 2.213Urban TFR 7.320 2.782 2.715 2.649 2.582 2.515 2.449 2.382 2.316 2.249 2.196Total TFR 7.940 2.839 2.767 2.696 2.624 2.552 2.480 2.408 2.337 2.265 2.207

(d) Rural-Urban Transition

12. The rural-urban transition in the projections shifts part of therural population to, urban areas each year. During the inter-censal period1960-1972, the rural areas grew at a rate of natural increase of 2.71%.Under the assumption that rural areas would have grown at 3.5% had there beenno shift to urban areas, the rural-urban transition during 1961-72 was cal-culated to be about 26% of expected rural growth. The figure of 26% was usedto calculate the total rural-urban transition for each decade of the projec-tion period for projection one. Two-thirds of that figure was used for pro-jection two, and one-third for projection three. No transition was assumedfor projection four. Table A-5 gives the specific figures used in theprojections.

APPENDIX 1-76 - Page 8

Table A-5: RURAL-URBAN TRANSITION FIGURES

ExpectedGrowth in

Rural Expected Transition Per Year ('000)- Popuilation Transition Proj. 1 Proj. 2 Proj. 3 Proj. 4

('000) (' 00)

(1972-77) 497 497 4971972-1982 18,866 4,972 497 (1977-82) 331 166 01982-1992 25,467 6,712 671 447 224 01992-2002 34,376 9,060 906 604 302 02002-2012 46,403 12,230 1,223 815 408 02012-2022 62,637 16,509 1,651 1,101 550 0

13. The age-sex ratio of the population undergoing transition assumedthat half of the transition was due to migration and half was due to urbanannexation of neighboring rural areas. The sex ratio of the transition popu-lation was 125, based upon a sex ratio of 145 for migrants in Pakistan duringthe period 1951-61 and a ratio of 105 among the rural population. The agestructure used the average of the age structure of the rural population andthe assumed age structure of the migration population. The resulting agedistribution is as follows:

Table A-6: AGE DISTRIBUTION OF RURAL POPULATION BECOMING URBAN

Age Structure ofAge Group Transition Population

Male Female

0- 4 .066 .1355- 9 .141 .162

10-14 .146 .22915-19 .214 .19820-24 .191 .105

25-29 .103 .04430-34 .036 .02435-39 .018 .01040-44 .006 .02145-49 .016 .016

50-54 .016 .01355-59 .005 .01260-64 .017 .01265-69 .006 .00670+ .019 .013

APPENDIX 1Page 9

(e) Labor Force Supply

14. The labor force supply was calculated by applying labor force parti-cipation rates for all age groups to the population in those age groups for

each of the four projections. The initial labor force participation rates

were derived from the 1973 Housing, Education, and Demographic Survey. Begin-ning in 1977, participation rates for both males and females outside the

15-64 age group were linearly declined to reach zero in 2021. Within the15-64 age group, male participation rates were held constant, while femalerates were linearly interpolated beginning in 1977 to reach the 1975 U.S.

rates in year 2021. The following table summarizes the participation ratesused.

Table A-7: LABOR FORCE PARTICIPATION RATES UTILIZED FOR PROJECTIONS

1973 HED Survey 2021 Projected LaborAge Group Labor Force Participation Rates Force Participation Rates

(Percent) (Percent)

Male Female Male Female

10-14 39.48 10.34 0 0

15-19 67.71 8.65 67.71 42.820-24 87.42 10.81 87.42 64.3

25-29 94.61 8.60 94.61 54.630-34 96.31 8.79 96.31 54.6

35-39 96.99 8.21 96.99 55.8

40-44 96.72 8.59 96.72 55.845-49 96.33 7.68 96.33 54.6

50-54 94.30 9.47 94.30 54.655-59 90.81 7.30 90.81 41.0

60-64 85.56 8.57 85.56 41.065-69 78.27 7.47 0 070-74 68.89 8.29 0 0

75+ 54.29 10.68 0 0

- 78 -

APPENDIX 1

Page 10

Table A-8: POPULATION PROJECTIONS (1977-2017) BY SELECTED SOCIOECONOMIC GROUPSLa

(million)

1977 1982 1987 1992 1997 2002 2007 2012 2017

Total PopulationSeries 1 79.3 94.2 112.8 137.1 168.1 206.7 254.3 315.1 391.2Series 2 79.7 93.5 110.4 131.3 156.3 184.9 216.6 250.3 286.1Series 3 79.7 90.9 100.1 107.0 115.7 126.1 137.5 148.8 159.3Series 4 78.7 81.9 86.5 92.8 100.6 108.3 115.3 121.3 126.6

Urban PopulationSeries 1 25.5 33.3 44.0 57.7 75.9 98.5 128.1 165.3 214.2Series 2 25.4 32.0 40.6 51.0 63.9 78.2 94.8 112.4 132.8Series 3 25.3 30.0 34.2 37.5 41.5 46.2 51.8 57.5 63.7Series 4 25.0 26.3 23.1 30.3 33.0 35.6 37.9 39.8 41.6

Primary School Age (5-9) PopulationSeries 1 12.1 14.1 16.8 21.0 26.6 33.4 41.1 50.8 63.2Series 2 12.1 14.1 16.3 19.4 23.4 27.8 31.8 35.3 37.7Series 3 12.1 14.1 14.2 12.4 9.9 11.6 13.7 15.0 15.2Series 4 12.1 14.1 6.0 7.3 9.0 10.7 11.1 10.6 9.9

High School Age (10-14) PopulationSeries 1 9.9 12.0 14.0 16.7 20.9 26.5 33.3 41.1 50.7Series 2 9.9 12.0 14.0 16.2 19.3 23.3 27.7 31.7 35.2Series 3 9.9 12.0 14.0 14.1 12.3 9.9 11.5 13.6 15.0Series 4 9.9 12.0 14.0 6.0 7.3 9.0 10.7 11.1 10.6

Population of Working Age (15-64)Series 1 38.7 46.1 54.8 65.5 78.4 95.2 117.3 145.5 181.2Series 2 38.7 46.1 54.8 65.5 77.9 93.1 112.0 134.6 160.9Series 3 38.7 46.1 54.8 65.5 75.8 84.1 89.7 96.4 104.9Series 4 38.7 46.1 54.8 65.5 67.7 71.1 75.8 81.7 87.8

Labor Force SupplySeries 1 23.5 28.1 33.9 41.3 50.5 62.6 78.4 99.0 125.6Series 2 23.5 28.1 33.9 41.2 50.1 61.1 75.0 91.9 112.2Series 3 23.5 28.1 33.9 40.9 48.3 55.0 60.9 67.0 74.2Series 4 23.5 28.1 33.9 39.6 43.8 47.3 51.7 56.7 62.0

Women in Childbearing Age (15-49)Series 1 15.2 18.2 22.0 25.7 32.5 40.3 50.5 62.9 78.2Series 2 15.2 18.2 22.0 25.7 32.3 39.3 48.0 57.6 68.4Series 3 15.2 18.2 22.0 25.7 31.2 35.0 37.1 39.0 41.1Series 4 15.2 18.2 22.0 25.7 27.3 28.6 30.4 31.9 32.8

/a Assumptions

(1) Base population:Total: 1972 censos count adjusted for 6.3 percent under-enumeration according to Census Evaluation Survey.

Age-Sea and Rural-Urban Distribution: 1972 Housing, Education Derogrnphic Survey adjusted to conform with1972 census count.

(2) Mortality: Coale-Demeny Weat family of Modsl Life Tables with initial expectation of life at birth as estimatedby Parooqui and Alan for 1970 vere utilized. Changes per year were graduated according to actual level (e0 lessthan 60) and aex varying from 0.7 years ohange per year for low level females to 0.1 per yeor for high level males.

(3) Percility:(i) Age-specific fertility rates based on Population Growth Experiment and urban-rural differences

from the 1971 Population Growth Survey.(ii) Slow change - urban fertility constant for 5 years and decreased at 1% for 17 years, 2% for

9 years, 3% for 8 years and 11% thereafter; rural fertility constant for 5 years and decreasedat 1% for 28 years, 2% for 9 years and 3% thereafter.

(iii) Fast change - both urban and rural fertility constant for 5 years, then reduced at 0.4 pointsannually for 13 years (to replacement level for urban population) and held constant thereafter.

(iv) Reduction to replacement level - fertility constant for 5 years, urban fertility rate reducedto 2.8 and rural fertility rate to 2.86 in the sixth year, and then linearly reduced to replace-ment level in the last year of projection period.

(4) Rural-Urban Transition: Growth of urban areas in addition to natural growth. Age-sea distribution assumed 50 percentof transition due to rural-urban migration and 50 percent due to urban annexation of neighboring rural areas. Totaltransition about 25 percent of rural growth in projection one, 16 percent in projection two, 8 percent in projectionthree, and zero in projection four.

(5) Labor Porce Supply: Initial labor force participation rates based upon 1972 Housing, Education and Demographic Survey.For males, labor force participation rates in the 15-64 age group kept constant: for females, rates in the 15-64 agegroup linearly interpolated beginning in 1977 to reach the 1975 U.S. rates in the year 2021. For both males and females,participation rates outside the 15-64 age group linearly declined beginning in 1977 to reach zero by 2021.

Sources: Pakistan Census Organization. Population Census of PAkistan, 1972. Provisional Tables. Census Bulletin No. 1,nlaamabad, 1973.

Pakistan Statistical Division. Census Evaluation Survey: Population Census 1972, Karachi, 1974.

Pakistan Census Organization. Housing, Education and Demographic Survey. 1972. Computer Printouts, Islamabad, 1976.

Coal., A.J., snd Paul Deceny, Regional Model Life Tables and Stable Populations. Princeton, Princeton University Press, 1966

Farooqui, Naseem lqbal and Iqbal Alam. "Provincial Abridged Life Tables for Urban and Rural Areas in Pakistan, based onPGS 1968 and 1971." The Pakintan Development Review, Vol. XIII, No. 3, Autumn 1974, pp. 335-352.

Zanchariah, R.C., and R. Cuca. Population Projections for Bank Member Countries. 1970-2000, World Bank (mimeo), 1973.

Farooqui, M. Naseem Iqbal and Ghazi Mumtee Farooq. Final Report of the Population Estimation Emperiment, 1962-65.Dacca: Pakistan Institute of Development Economics. 1971.

Pakistan Statistical Division. Population Growth Survey, 1971. Karachi, 1974.

Planning Commission, Government of Pakistan. Working Paper for Fifth Plan (1977-83), October 1976.

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APPENDIX 1

Table A-9: POPULATION PROJECTIONS (1977-2017): VITAL RATESa Page 11

1977 1982 1987 1992 1997 2002 2007 2012 2017

Crude Birth Rate (per thousand)Series 1 43.9 44.7 46.3 47.6 47.7 47.3 47.2 47.4 47.7Series 2 43.5 42.5 42.5 42.5 40.8 38.7 35.4 32.6 29.8Series 3 41.7 32.3 23.2 21.2 23.6 24.4 23.2 21.0 19.2Series 4 16.0 18.1 20.8 23.5 23.5 21.2 18.5 16.4 15.6

Crude Death Rate (per thousand)Series 1 12.2 10.0 8.7 7.4 6.6 5.8 5.1 4.5 4.0Series 2 12.1 9.9 8.6 7.3 6.5 5.8 5.2 4.7 4.4Series 3 12.0 9.3 7.8 6.9 6.9 6.7 6.6 6.3 6.4Seriea 4 10.7 8.5 8.3 7.8 7.6 7.3 7.2 7.3 7.5

Rate of Natural Increase (percent)Series 1 3.17 3.47 3.76 4.02 4.11 4.15 4.21 4.29 4.37Series 2 3.14 3.26 3.39 3.52 3.43 3.29 3.03 2.79 2.54Series 3 2.97 2.30 1.54 1.42 1.67 1.76 1.66 1.47 1.29Series 4 0.54 0.96 1.25 1.57 1.58 1.38 1.13 0.92 0.80

Total Fertility Sate (per woman)Series 1 7.900 7.874 7.845 7.821 7.791 7.767 7.746 7.731 7.712Series 2 7.821 7.422 7.042 6.685 6.241 5.801 5.185 4.615 4.054Series 3 7.501 5.498 3.496 2.731 2.720 2.712 2.706 2.701 2.691Series 4 2.839 2.767 2.696 2.624 2.552 2.480 2.408 2.337 2.265

e8 Hales (in years)Series 1 57.3 60.2 62.4 64.4 65.8 66.8 67.9 68.9 69.8Series 2 57.3 60.2 62,4 64.4 65.8 66.8 67.8 68.8 69.8Series 3 57.3 60.2 62.3 64.3 65.7 66.7 67.7 68.8 69.7Series 4 57.3 60.1 62.3 64.3 65.7 66.7 67.7 68.7 69.7

e8 Females (in years)Series 1 57.1 60.6 63.1 65.5 67.0 68.5 70.0 71.1 72.1Series 2 57.1 60.5 63.1 65.4 67.0 68.5 69.9 71.1 72.1Series 3 57.1 60.5 63.0 65.4 66.9 68.4 69.9 71.0 72.0Series 4 57.1 60.5 63.0 65.4 66.9 68.4 69.9 71.0 72.0

Rural-Urban Transition: Males (thousand)Series 1 276 373 373 503 503 679 679 917 917Series 2 184 248 248 336 336 453 453 612 612Series 3 92 124 124 168 168 227 227 306 306Series 4 0 0 0 0 0 0 0 0 0

Rural-Urban Transition: Females (thousand)Series 1 221 298 298 403 403 544 544 734 734Series 2 147 199 199 268 268 362 362 489 489Series 3 74 100 100 134 134 181 181 244 244Series 4 0 0 0 0 0 0 0 0 0

La Assumptions

(1) Baae population:Total: 1972 census count adjusted for 6.3 percent under-enumeration according to Census Evaluation Survey.

Age-Sex and Rural-Urban Distribution: 1972 Houaing, Education, Demographic Survey adjusted to conform with 1972 census cpunt

(2) Mortality: Coale-Demeny West family of Model Life Tables with initial expectation of life at birth as eastimated by Farooquiand Alan for 1970 were utilized. Changes per year were graduated according to actual level (ea less than 60) and sexvarying from 0.7 years change per year for low level females to 0.1 per year for high level malea.

(3) Fartility:(i) Age-specific fertility rates based en Population Growth Experiment and urban-rural differences from

the 1971 Population Growth Survey.(ii) Slow change - urban fertility constant for 5 years and decreased at 1% for 17 years, 2% for 9 years,

3% for 8 years and 112 thereafter; rural fertility constant for 5 years and decreased at 1% for28 years, 2% for 9 years and 3% thereafter.

(iii) Past change - both urban and rural fertility constant for 5 years, then reduced at 0.4 pointsannually for 13 years (to replacement level for urban population) and held constant thereafter.

(iv) Reduction to replacement level - fertility constnt for 5 years, urban fertility rate to 2.86 inthe sixth year, and then linearly reduced to replacement level in the last year of prolaction_periodt-

(4) Rural-Urban Transition: Growth of urban areae ilLaddiction-to.-naturasriawth' Age-sex distribution assumed 50 percent oftransition due to rural-urban migration and 50 percent due to urban annexation of neighboring rural areas. Total transitionabout 25 percent of rural growth in projection one, 16 percent in projection two, 8 percent in projection three, and zeroin projection four.I

Sources: Pakistan Census Organization. Population Census of Pakistan, 1972. Provisional' Thl,a, Census Bulletin No. 1, Isle,aba41973. a&d

Pakiotan Statistical Division. Census Evaluation Survey: Population Census 1972. ISarachi, 1974.

Pakistan Census Organization. Meusic. Education and Deomgraphic Survey. 1972. Conputer Printouts, Islamabad, 1976.

Coale, A.J.. and Paul Demeny, Resional Model Life Tables and Stable Populations, Princeton, Princeton UniversityPress, 1966.

Farooqui, Naseem Iqbal and Iqbal Alan. 'Provisional Abridged Life Tables for Urban and Rural Areas in Pakistan, based onP0S 1968 and 197L" The Pakistan Developmeot Review, Vol. Y1II, No. 3. Autumn 1974, pp. 335-352.

Zachariah, K.C.,.and R. Cura. Population Proiections for Bank Member Countries. 1970-2000, World Bank (ameo), 1973.

Parooqui, M. Naseem Iqbal and Ghasi Mutaz Farooq. Fin-l Report of the Population Growth Estimation Experiment,1962-65.

Dacca: Pakistan Institutea of Development Economics, 1971.

Pakistan Statistical Division. Population Growth Survey. 1971. Karachi, 1974.

Planning Commisaion, Government of Pakistan. Workina Paper for Pifth Plan (1977-83), October 1976.

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