ThirdWorld Quarterly, Vol 16, No 2, 1995 Linkingnational and global populationagendas: case studies from eightdeveloping countries KELLEYLEE &GILLWALT

Duringthe past 40 years therehave been numerous initiatives on population at theglobal level and, in particular, the promotion of measures tomoderate populationgrowth through family planning ( FP).Manyhigh-level conferences andmeetings have been held, generally followed by large amounts of ® nancial assistance toencourage governments of developing countries to adopt policies andprogrammes to reduce fertility rates. 1 Mostrecently held has beenthe InternationalConference on Population and Development in September 1994, a high-pro®le meetingin Cairo which sought to de® ne andbroaden the population agendafor the coming decade amid extensive media attention. The Cairo conferencehas beenone of severalheld or planned by the United Nations since themid-1980s to address broadthemes. 2 TheLondon School of Hygiene and Tropical Medicine, funded by the UN PopulationFund, has coordinateda studyof FP policiesand programmes in four pairsof developing countriesÐ Zambia/ Zimbabwe,/ ,Pakistan/ Bangladesh,and the / Thailand. 3 Eachpair of countrieswas chosenfor theirrough cultural and economic similarity, but dissimilarity in terms of populationpolicy and implementation. The purpose of choosing similar coun- trieswas toachieve a clearerunderstanding of why and how some developing countriescreate appropriate and effective population policies while other, rather similarcountries, do not. The study itself consisted of two parts: apolicy analysisof the historical determinants of FP policiesin terms ofpolicy actors, processes andcontexts; and a demographicanalysis of the consequences of FP policiesin terms offertility rates andother indicators. Drawing on the policy analysisfrom the study, one of the key questions addressed was whethera link couldbe madebetween policy making at the global and national levels. After all thehype and fanfare of international conferences, followed by well-intended declarationsand ® nancialpledges, to what extent do these global-level efforts actuallyin¯ uence national policy makers? And,if they do, under what circum- stances? Inshort, to whatextent has theglobal population agenda led to greater commitmentto FP atthe national level by governments? Overallit was foundthat, in the four pairs of case studycountries, national FP policiesand programmes have been shaped to a varyingdegree by global developments.The extent of this in¯ uence has dependedon the compatibility betweennational and global policy contexts. First, it is heldthat the degree of supportby a governmentfor FP has correspondedwith that country’ s relations withWestern countries over time. The closer a country’s politicaland economic

0143-6597/95/020257-16 Ó ThirdWorld Quarterly KELLEY LEE &GILL WALT relationswith Western countries, the more receptive national policy elites have beento the global population agenda. 4 Second,it is heldthat support for FP has beenin¯ uenced by changingeconomic circumstances in each country, as wellas particulardevelopment strategies pursued. When economic problems (including landpressure andscarcity of naturalresources) havebeen perceived as urgentby policyelites, FP has tendedto be higher on national policy agendas. This has beenespecially so wherea governmenthas adopteda developmentstrategy basedon rapid economic growth, 5 whichrecognises a directlink between limitingpopulation growth and increased economic development. 6

Puttingfamily planning on the policyagenda: the 1950sto 1974 Analysingthe changing political and economic characteristics of the case study countries,and the global population agenda from the 1950s, we see thattheir politicaleconomies have strongly shaped the context within which FP policies andprogrammes have been either supported or opposed.During the 1950s only Pakistan(then including Bangladesh) and Rhodesia (then including Zimbabwe andZambia) had nascent FP activities.For the other countries, FP was eithernot yetseen as anarea oflegitimate concern by government (Philippines, Tunisia) orthere were strong pronatalist attitudes (Thailand, Algeria). Followingindependence in 1947, Pakistan remained closely allied with Westerncountries. During 1954-55 it joinedthe US-sponsored military alliances ofthe Southeast Asian Treaty Organisation ( SEATO)andthe Central Treaty Organisation( CENTO),7 andfrom the late 1950s onwards, under Sandhurst-edu- catedPresident Ayub Khan, `established itself as atestcase incapitalist developmentstrategy aligned to the Western power bloc and heavily dependent onUS economicand military aid’ . 8 Itwas as partof Ayub Khan’ s embraceof prevailingWestern ideas about development that the government saw the limitationof population growth as importantto the country’ s modernisation.As hedeclaredin 1959,`the menace of overpopulationand rapid rate of population increaseexists in most underdeveloped countries, and a bigconcentrated drive is necessary toeducate the people about the evils of overpopulation’ . 9 Initially thisled to limited FP services providedby voluntaryorganisations in urbanareas. By1960 Pakistan became one of the ® rst countriesto adopt an of® cial policy toslow population growth, and to negotiate assistance fromthe Population Council. InRhodesia the ® rst FP services wereintroduced by andlargely for the white populationsof Harare and Bulawayo in the mid-1950s. These limited services wereprovided by twovoluntary organisations, 10 withthe ® nancialand technical supportof the US-based Path® nder Fund. The primary motivation for introduc- ing FP atthistime was healthrather than the reduction of fertility.The response tothese early efforts was mixed:most whites were indifferent and in some cases morallyopposed to FP,whileblacks were sensitive to the racial overtones of `birthcontrol’ . 11 Bythe 1960s there was anotableincrease in attention at the global level towards FP.Thisshift was ledby Western countries, notably Scandinavian and laterthe USA, which`pushed harder than any other Western government for 258 NATIONAL AND GLOBAL POPULATION AGENDAS developingcountries to adopt population policies’ . 12 TheUS Agencyfor InternationalDevelopment ( USAID)becamethe largest single donor for popu- lationprogrammes, totalling US$3.9 billion between 1968± 88. 13 Fromthe late 1960sit was joinedby multilateralaid from the , the United Nations Fundfor Population Activities ( UNFPA)(createdin 1969) and to a lesser extent theWorld Health Organization ( WHO).14 Theseefforts were greatly assisted by theincreased availability of the intrauterine device ( IUD),sterilisationand oral contraceptivesin the 1960s which made possible active and widespread interven- tionin fertility behaviour. These methods proved popular among users in industrialisedcountries, and donors were keen to fund their distribution in developingcountries. Finally, the results of macroeconomic studies and simula- tionsprovided evidence for supporters of FP thatrapid population growth was a problemfor many developing countries. 15 Amongthe case studycountries, how this international enthusiasm for FP was receiveddepended on their respective political and economic relations with Westerncountries. Because ofa closeidenti® cation of the global population agendawith Western governments, FP tendedto come onto the policy agenda earlierin thosecountries which had closer relations with the West. Alternatively, inthose countries which maintained more distant and even hostile relations with the West, FP was seen tobeinthe interests of Westerngovernments rather than thedeveloping world. Thisis well-illustratedby comparing the policy contexts of Tunisia and Algeriaduring this period. Like Pakistan’ s AyubKhan, and despite the adoption ofsocialistpolicies, President Habib Bourguiba of Tunisiawas astrongadvocate ofmodernisation based on open relations with Western and developing coun- tries.Tunisia gained independence peacefully in 1956 and subsequent relations withWestern countries, particularly , were less taintedthan for Algeria. Atthe same time,as amemberof the Nonaligned Movement ( NAM) and Group of77, the government was anactive participant in the development of North± Southdebates. It was inthis context of openness towards the West that FP was acceptedas partof a broaderagenda for economic development. As President Bourguibastated in 1962, `What good will it do if we expand our industriesand increase our national income, if we cannot control population growth?’ 16 Internationally,Tunisia became one of the early sponsors of a -ledresolution put forth at the UN GeneralAssembly in 1962 on `Populationgrowth and Economic Development’ . 17 Incontrast,commitment to FP inAlgeria was muchweaker. Following its war ofindependencewith France (1954± 62), Algeria aligned itself strategically with theSoviet Union. Rejecting Western ideas about development as neo-imperialist, thegovernment followed the Soviet model of developmentand became an active member of OPEC in 1969, the NAM andGroup of 77. 18 Itwas as partof this anti-imperialiststance that the need to limit population growth was rejectedas aWestern-imposedissue aimedat weakening rather than assisting developing countries.This wariness towards Western domination was re¯ected in a motion adoptedby theNational Union of AlgerianWomen ( UNFA)in1966which stated that FP beprovided with: 259 KELLEY LEE &GILL WALT

strictmedical control and training of quali® ed personnel¼ in order not to fall into theproblem met by several countries where foreigners have themselves imple- mentedthe family planning structures, in place of nationals, neglecting both medicalcontrol and human contact. 19

Itwas inthis unreceptive environment that FP was initiallyintroduced in Algeria in1966Ð in supportof maternaland child health ( MCH)Ðbutlater dropped from publicpolicy as PresidentBoumedienne became increasingly vocal against `false solutionslike birth control’ for the problems of development. Asimilardistrust of foreign in¯ uence existed in Zambia after the country gainedits independence through elections held in 1964. The new government underPresident Kenneth Kaunda adopted a politicaldoctrine of `humanism’ in 1967which aimed `to build on traditional African values and¼ the creation of asocietybased on mutual assistance andequal opportunity’ . 20 This form of Africansocialism, amid struggles for independence throughout southern Africa, was alignedneither with the West nor the Soviet bloc. Instead Zambia became astaunchmember of the NAM andits political leaders denounced colonial rule andinternational capitalism, and nationalised key industries such as miningand manufacturing.In this context, Western-led support for FP was likelyto be seen as partof a colonialpast which newly-independent countries needed to reject. Indeedrapid population growth was notseen asanimmediateproblem by policy elitesduring this period of relative economic prosperity. With vast reserves andhigh commodity prices, it was believedthat the mining industry wouldserve as theengine of Zambia’ s economicdevelopment. Between 1964± 72copper provided over 92% of export earnings and an average of 52% of governmentrevenues. 21 Furthermore,with only four persons per square kilome- tre in 1960,22 therewas aperceptionof plentiful land and resources among policyelites. Thus the government was less concernedabout population growth thanother population issues suchas rapidand large-scale urbanisation. 23 WhileAlgeria and Zambia remained unreceptive to growing global concerns aboutpopulation growth, policy makers inPakistan, Thailand and the Philip- pinesproved more responsive during the 1960s. Building on theinitial efforts of the1950s, the government of Pakistan launched a large-scaleNational Family PlanningScheme in 1965. The programme received extensive support from externaldonors who poured money, contraceptives and personnel into the country(US$6.8 million annually between 1966± 68). More generally, this was alsoa highpoint in relations between Pakistan and Western countries, which providedUS$480 million of economic aid to the country between 1966± 68. 24 AbroadPakistan played a prominentrole at the UN inthe early 1960s in its supportof Sweden’ s effortsto put population on the agenda. The head of the Swedishdelegation described Pakistan as `theonly rock to count on’ and `the mostfaithful brother’ . 25 Thegovernment also contributed actively to the Asian PopulationConference (1963) where participants requested greater UN assist- ance for FP.26 Inboth Thailand and the Philippines, close political and economic relations withWestern countries was accompaniedby the identi® cation of FP as an issue onthenational policy agenda from the mid- to late 1960s. Following the second 260 NATIONAL AND GLOBAL POPULATION AGENDAS

WorldWar both countries formed close ties with the USA giventheir strategic importanceto the US policyof `containment’in Southeast Asia. 27 Asa`bastion againstcommunist expansion’ , Thailandreceived over US$2 billion of military aidfrom 1951± 71 andUS$650 million of economicaid from 1950± 75. Under a militarygovernment this aid was usedto build a strongdefence and police force, anda well-developedroad system tocombat counter-insurgency movements. Thailand’s economicrelations were also closely aligned with the West during thisperiod and dated as far backas theBowring Treaty (1855) which opened tradewith colonial powers. During the 1950s and 1960s, the government of PrimeMinister Sarit actively encouraged foreign investment and sought substan- tialloans and grants from foreign sources (primarilythe USA andWorld Bank) forinfrastructural investment. 28 ThePhilippines also maintained close relations withthe USA followingits liberation from Japanese occupationin 1945, and despitecutting the formal colonial bond in 1946, signing the Military Bases and MilitaryAssistance Agreements in 1947 and a MutualDefence Treaty in 1951. AsinThailand,large amounts of Westernaid and foreign investment ¯ owedinto thecountry, and free tradebetween the Philippines and USA closelylinked the economyto US markets.By 1970US interestscontrolled more than 25% of the industrialsector and 80% of foreign equity in the Filipino economy. 29 Givenclose political and economic relations with Western countries, it appearsthat the policy contexts in both Thailand and the Philippines were more receptiveto developmentsin theglobal population agenda. In Thailand it was a studysubmitted by the World Bank in 1958 which ® rst drewthe government’ s attentionto the country’ s rapidlyincreasing population. 30 Thestudy led to a series ofpopulation seminars duringthe 1960s attended by a widerange of governmentof® cials and external donors, followed by the declaration of the NationalPopulation Policy in 1970.In the Philippines the in¯ ows of externalaid includedfunds from USAID,theFord Foundation and the Population Council to studypopulation issues andinitiate family planning activities. These efforts culminatedin the creation of the Commission on Population in 1969 aimed at `reducingpopulation growth’ as `anurgent national need’ . 31

Shifting momentumin adecadeof change: 1974 to 1984 Itwas atthe UN-sponsored World Conference on Population held in Bucharest inAugust 1974 that disagreement regarding the link between population growth anddevelopment came tothe fore at the global level. To a largeextent, the conferencewas anextension of demandsby members ofthe NAM and Group of 77for a NewInternational Economic Order ( NIEO).Manydeveloping countries rejectedthe argument that there was aneedto limit population growth before economicdevelopment could occur. Instead the slogan `development is thebest contraceptive’was adopted,arguing that development (through a NIEO) would reducepopulation growth. As presidentof the NAM,andas partof its anti-imperialist stance, the governmentof Algeria `refused [ FP]¼ as analternative to development’ . As arguedby President Boumedienne at the UN GeneralAssembly later the same year,there was aneedfor a radicalrestructuring of international economic 261 KELLEY LEE &GILL WALT relationsin favour of developing countries. 32 Itwas `constructingan economy capableof satisfyingall the cultural and material needs of the Algerian people’ 33 thatwould lead to a declinein fertility. For the Algerian economy such a strategy,in the form of anationalisedoil industry and membership of OPEC, was alreadyseen asbene®cial. Indeed, given a dramaticrise inoilrevenues, Algeria was itselfable to become an aid donor during the 1970s. 34 Thisseemed to reaf® rm thegovernment’ s positionon North±South issues, andto keep FP off the policyagenda. Inremarkable contrast, the 1970s was aperiodof acceleration of the FP programmein Tunisia,with expanded access toa widervariety of contraceptives throughoutthe country. 35 Atthe same timethe government continued to pursue arelativelyopen door policy towards Western countries, actively pursuing exportmarkets, encouraging foreign investment, expanding the tourist industry andworking closely with the World Bank. 36 Incomparing Zimbabwe (then Rhodesia) and Zambia, we can see thatthe 1970swas aperiodof civilwar for Zimbabwe, with much of the health system (including FP services) breakingdown. While the privately-administered Family PlanningAssociation continued to operate in mainly urban areas, thealready weakrural services becameincreasingly ineffective. Exacerbating this situation was thestrong anti- FP stanceof Africannationalists who. as Westwrites, `set out systematicallyto destroy the rural-based family planning infrastructure’ . 37 See- ing FP as anintegral part of theracist Rhodesian government, nationalists argued thatthe population problem lay in thecrowding of blacksonto barren `tribal trust lands’, whilea fewthousand white farmers ownedthe most fertile parts of the country. Zambiacontinued to vocalise the concerns of the developing world in such foraas theOrganisation for African Unity ( OAU),Groupof 77, the United NationsConference on Trade and Development ( UNCTAD)andthe Common- wealth.As anextension of Kaunda’ s `humanism’, Zambia’s foreignpolicy focusedon demands for greater political and economic equality for developing countries.In addition, the government was becomingincreasingly preoccupied withregional and domestic problems, with struggles for independence through- outsouthern Africa bringing Zambia closer to a positionof nonalignment. This ledthe government to join Algeria, and other members ofthe NAM at the UNinopposing calls to limit population growth. Furthermore the government faceda worseningeconomy by the mid-1970s as worldcommodity prices droppedsharply, import prices soared, and government revenues declined. As a result, grew between 1975± 80 from US$1.38 billion to US$2.66 billion.38 Amiddomestic turmoil, FP was notan immediate priority on thepolicy agendasof either country. Thiswas notthe case ineither Bangladesh or Pakistan.War also disrupted the healthsystem inthe former East Pakistan (now Bangladesh) where, immediately followingindependence in 1971, the government followed a socialistroute. The Mujibregime was suspiciousof the West at this time because it believedthe USA supportedPakistan during the war. The new government was notopposed to FP per se, holdinga NationalSeminar on Population Control and Family Planning in 1972 andincluding FP inthe country’ s ®rst FiveYear Plan ( FYP)(1973±78), 262 NATIONAL AND GLOBAL POPULATION AGENDAS butother priorities such as rebuildingthe country’ s economyand responding to naturaldisasters seem tohave taken precedence. After the assassination of PresidentMujibur Rahman in 1975, the new military government sought closer politicaland economic relations with Western countries. This brought substantial amountsof externalaid and Bangladesh soon became one of the world’ s largest aidrecipients. 39 Fordonors, such as USAID andthe World Bank, FP needed to be highon the policy agenda. Land pressures hadintensi® ed, with population densityincreasing from 290 to 463 persons per square kilometre between 1950±1970.40 Furthermorethe average size ofland ownership per household decreasedfrom 1.09 to 0.78 hectares between 1960± 80, with 45% of rural householdshaving no land at all. 41 Itwas thusfrom the mid-1970s that FP was givenstrong support by a governmentincreasingly dependent on external aid, andby Western donors convinced of the need to limit population growth. Relationsbetween Pakistan and Western countries remained positive through- outthe 1970s. Foreign aid as aproportionof GNP rose from5.9% to 10.5% between1973± 77, 42 withdonors such as USAID remainingkeen to support FP in Pakistan.Yet, perhaps surprisingly, this was aperiodof decline in government support for FP.As Khanwrites, domestic politics rather than strained foreign relationshindered FP duringthis period. With the close identi® cation of FP with AyubKhan, the programme became highly politicised and therefore dif® cult to supportfor the new government. 43 Moregenerally the struggle for political powerduring the Zul® qar Bhutto regime had wide-ranging effects onPakistani society.This included sweeping reforms ofthe civil service beginning in 1973, whichsubstantially reduced its policy making role. It also led the government to divertresources fromthe planned expansion of social services, such as the People’s HealthScheme, to defence and public administration. 44 Acomparisonof Thailandand the Philippines shows that relations with the West onlypartly explains the difference in the effectiveness of their FP policiesand programmesduring this period. In Thailand the rise ofcommunism in Vietnam, Laosand Cambodia strengthened the government’ s strategiclinks with the USA, andthe country served as amilitarybase forlarge numbers of American troops. At thesame timeThailand experienced its own civil unrest following the overthrow ofthe military government in 1973. By 1977, after several changes of government andthe suppression of left-wing groups (ie labour unions, students and farmers), themilitary again took political control of the country. 45 Theseevents seem tohave hadlittle effect on FP inThailand. The programme continued to receive increasing funding,largely from external donors until 1981, when the government began to contributea growingshare. FP activitiesexpanded accordingly, with targets set and metafter each FYP.46 Itappears that, despite domestic upheavals among a small numberof politicalelites, the bureaucracy remained a stableand functioning part ofgovernment. Thus, unlike in Pakistan, the implementation of FP policiesand programmesremained effective. Inthe Philippines, despite the imposition of martial law by President Marcos in1972, there continued to be close ties with the USA. Thecountry remained animportant ally in Southeast Asia and continued to receive large amounts of militaryand economic aid. Between 1972± 73 alone military aid increased from US$18.5million to US$45.3 million. 47 Marcos alsowooed the USA byallowing 263 KELLEY LEE &GILL WALT foreignownership of businesses,notably in the and fruit industries. Given thispositive relationship with the West, it is perhapssurprising that the FP programmein thePhilippines received far less supportfrom political elites than inThailand during this period. While the government appeared strongly commit- ted to FP inthe late 1960s, when it was ®rst placedon the policy agenda, subsequentphases inthe policy process havebeen less effectivelyfollowed up.

Con¯ict andconsensus: The1984 Mexico City conference

WhileAlgeria and Zambia were vocally against FP in1974,their positions were markedlydifferent by thetime the International Population Conference was held inMexico City in 1984. Overall there was increasedconsensus among develop- ingcountries, as wellas donorsand NGOs, onthe need to limit population growth.An importantpart of theexplanation for this dramatic change of position canbe foundin structural shifts in the global which, inter alia, weakenedthe bargaining power of developing countries and increased their dependenceon Western aid (eg the debt crisis). In turn, these shifts had implicationsfor policy makers atthe national level including the rise of neoliberalparadigms of development. Overall these changes created a policy contextmore conducive to FP.MostWestern countries supported FP programmes indeveloping countries. This was justi®ed by growing evidence from many countries(eg China, Indonesia, Thailand) that FP programmescould be effective atcontrolling fertility. Shiftsin thepolitical economy of Algeriaprovide a goodexample of howthis, inturn, created a morefavourable policy context for FP.Bythe early 1980s revenuesfrom oil and gas exportsof the previous decade, accounting for nearly 90%of exports, 48 haddropped steeply with world oil prices. From being a relativelygenerous aid donor in the 1970s, 49 Algeriaincreasingly sought West- ernaid as foodshortages, in¯ ation and unemployment rose. The country was alsoin politicallimbo with the death of PresidentBoumedienne in 1979and the growingstrength of Islamic fundamentalism. Faced with looming political and economiccrises, thegovernment turned away from the ideological position of theNonaligned Movement and towards closer relations with the West. As Finkle andCrane write:

Togain economic concessions from theWest, [the Algerian government] found it increasinglyadvantageous to pursue bilateral or regionalapproaches rather than the globalstrategy associated with the NIEO¼theshift was aproductof growing economicpressures combined with changing leadership priorities. 50

Itwas duringthis period of changethat the government became more supportive of FP.In1983 Algeria adopted its ® rst PopulationPolicy and, after signing the WorldPopulation Plan of Action at the Mexico Conference, led calls for more externalaid for FP.Thishas beenthe position of the government since the mid-1980s,amid widespread reforms tobring the country closer to Western countriesthrough the development of a moremarket-oriented economy, and increasedforeign investment and trade. 51 Resistanceby Islamic fundamentalists 264 NATIONAL AND GLOBAL POPULATION AGENDAS tosuch reforms has beendisruptive and hindered the implementation of FP policiesand programmes. Acomparisonof FP policiesin Zambia and Zimbabwe, in relationto shifts in theirpolitical economies, also suggests that closer relations with the West had apositiveeffect on putting FP onthepolicy agenda. In Zimbabwe relations with Westerncountries remained warm after the country gained independence from whiteminority rule in 1980. The West had imposed sanctions against Rhodesia between1965-80, and was quickto provide aid to the new Zimbabwean governmentfor rehabilitation and reconstruction. Extensive links were devel- opedbetween the government and donor agencies, including funding for one- third of the FP programmein theearly 1980s. 52 FP services werealso part of the government’s strongemphasis on building the social sector. It was inthis contextthat the implementation of the FP programmeproved relatively effective (comparedto Zambia),with an apparentincrease in thecontraceptive prevalence rate(from 27% to 43%) and a reportedreduction of total fertility (from 6.6 to 5.4births per woman) between 1984± 88. 53 InZambia it appears that FP was alsoplaced on the policy agenda as aresult ofwarming relations with Western countries during the 1980s. Throughout the 1970sworld copper prices remained low, 54 whichled to crises inpublic ® nances bythe early 1980s. Faced with large de® cit spending, rampant in¯ ation (200% in1984) and rising foreign debt (about one-half of export earnings), the governmentwas increasinglyin need of foreign assistance. 55 Between1975± 80 externalaid increased by 400%,mainly from Western donors (eg Japan, the EC, andScandinavian countries), and Western countries (eg Japan and the UK) becameZambia’ s maintrading partners. With this economic dependence came policyconditionality. Between 1981± 88 the World Bank and IMF withheld selectedloans because of thegovernment’ s resistanceto `stabilisation’ policies. 56 TheZambian government’ s remarkablechange of policy on FP took place withinthis shift in political and economic relations with the West. With increasedattention to population growth in the late 1970s, eight major studies werepublished between 1981± 84 which provided demographic and statistical evidenceof the magnitude of this growth. These studies included the World Bank’ s AcceleratedDevelopment in Sub-Saharan Africa: An Agendafor Action, Zambia:Population, Health and Nutrition Sector Review (1984)and 1984 World DevelopmentReport onpopulation growth and development; and UNFPA’ s Zambia:Report of Missionon Needs Assessment for PopulationAssistance .57 Thesereports were accompanied by Zambia’ s participationin two major internationalconferences in 1984, the Second African Population Conference in Arushaand the International Population Conference in Mexico City. For both conferencesthe government needed to prepare statements on population growth inZambia, an exercise which, along with analyses of theabove studies, proved animportant catalyst for changes in FP policy.As Hopkinsand Siamwiza argue, theseinternational initiatives were important in putting population on thepolicy agendaand raising awareness ofthe need for FP.Theconferences, in particular, generatedwidespread media coverage and involved key government of® cials. 58 Itwas inthisvery changed policy environment that President Kaunda instructed 265 KELLEY LEE &GILL WALT theNational Commission for Development Planning to formulate the country’ s ®rst PopulationPolicy in 1985. 59 Whileit appearsthat closer relations with the West have led to ashifttowards greatersupport for FP inAlgeria and Zambia, a comparativeanalysis of the Philippines/Thailandand Pakistan/ Bangladeshshows that this link has beenless clear.In Thailandthe economy continued to growquickly throughout the 1980s despitea similarstarting point (in terms of GNP percapita during the 1960s) to thePhilippines. 60 GNP percapita doubled between 1971± 90, 61 andthe economic growthrate reached double digits between 1986± 90. 62 Tradeand investment relationswith Japan and other ASEAN members alsothrived throughout this period,as thecountry became increasingly integrated with the Paci® c Rimand worldeconomy. Domestically challenges for political power among political elitescontinued. However, these periodic struggles did not disturb the country’ s essentiallyoutward-looking, Western-orientated political economy. Nor did it deterthe ® rm commitmentby successive governmentsto FP policiesand programmes.By 1987± 91 the government was providingabout 87% of the funding for FP.63 Fromthe early 1980s differences between the political economies of Thailand andthe Philippines were increasingly apparent. The economy of thePhilippines sufferedbadly during the same period,with negative real growth during the mid-1980s.Foreign debt consumed about half the national income, exports of majorcommodities (eg sugar) fell by morethan two-thirds and levels of poverty increasedthroughout the country. By 1988 38% of the population lived below thepoverty line compared with 21% in 1971. 64 Theseeconomic problems led to majorcuts in public expenditure for social welfare and development purposes, including FP.Structuraladjustment which included measures toreduce public spendingwas introducedto the country in the late 1970s. 65 But,unlike in Algeria and Zambia, these economic problems did not lead to improvementsin FP.Indeed,the FP programmeperformed poorly throughout the 1980sin comparison with Thailand, with less steepand consistent declines in fertilityrates andlower use ofcontraception. An important explanation for this lackof effectiveness is theimpact of domestic upheavals on the country’ s responseto growing economic crisis. By the late 1970s rampant corruption, aid dependency,indebtedness and militarism brought together a diversepopular movementagainst President Marcos. The struggle for political power which ensued,continuing after the overthrow of the Marcos regimein 1986, led to muchsocial unrest. During this period relations with the West were also unstable.Tensions grew with the USA as PresidentCarter pressured the governmenton humanrights and Marcos threatenedto evictAmericans from the countryin response. 66 UnderPresident Aquino, a policyof self-suf® ciencywas adoptedwhich sought to reduce the country’ s dependenceon foreign aid. 67 For the FP programmein the Philippines, the combination of economicand political upheavalcreated a disablingpolicy context. The economic crisis meantdimin- ishingmeans topay for FP;thepolitical crisis meantit was dif®cult for governmentto act decisively. As aresult,it appears that the implementation of FP programmessuffered accordingly. Theimpact of political and economic changes on FP is less clearfor 266 NATIONAL AND GLOBAL POPULATION AGENDAS

Bangladeshand Pakistan. During the 1980s both countries experienced similar economicproblems with declining terms oftrade and growing foreign debt. In Bangladeshthis brought rising import prices in the face ofshrinking export markets.68 Unemploymentreached 30% in 1986 with 80% of the population livingbelow the poverty line. 69 Westernaid continued to keep the country a¯ , increasingfrom 8.5% of GDP in1974± 75 to 13.7% in 1981± 82. 70 InPakistan, despiteannual growth rates of GDP ataround 6% between 1977± 86, assisted by thegrowth in remittancesfrom overseas workersin the Middle East, the cost of servicingforeign debt was escalatingand sources offurther loans in decline. Againthis was mitigatedby Western aid, especially following the Soviet invasionof Afghanistan in 1979. 71 Thedifference between the two countries appears to liemore in their domestic politicsand, more speci® cally, the contexts in which Western donors have soughtto in¯ uence policy making in favour of FP.InBangladesh heavy dependenceon foreign aid has beenaccompanied by a directrole by donors in thepolicy making process. This has takenthe form of an aid consortium, created in1973 and led by the World Bank, whose reports on the Bangladesh economy andaspects ofdevelopmenthave been the main source of information for other donorsand even the government. 72 Itis perhapspartly because FP has remained highon the agenda of donors,and been a regularsource of foreignaid, that the governmenthas alsogiven FP ahighpriority. In contrast, domestic politics in Pakistanwas muchless subjectto the in¯ uence of donors.While foreign aid was clearlyimportant, and there were close links between policy elites and Western donors,the country’ s borderwith Afghanistan gave it greater strategic import- anceand, hence, a degreeof bargaining power that Bangladesh did not have. Thismay explain why expenditure on debtrepayment and defence grew rapidly duringthis period, while spending on the social sectors suffered.Between 1977±85 Pakistanhad one of theworst records of providingsocial services, with only® vecountries in the world spending less onhealth. This also affected allocationsfor FP,whichdeclined from Rs.202 million in 1976± 77 to Rs.177 millionin 1982± 83. 73 Thislow priority for social spending suggests that policy eliteswere more concerned with strategic matters. It was notuntil the latter half ofthe1980s that the government came underincreasing pressure fromthe World Bank, USAID andother donors `to show that something was beingdone in primaryeducation, health, and population’ . 74 Theimportance of aid to Pakistan broughtassurances frompolicy elites that population was highon their agenda. Inpractice these assurances ofpolitical commitment have yet to betransformed intoeffectively implemented programmes.

Towardsa newconsensus: the 1994Cairo conference and beyond TheInternational Conference on Population and Development, held in Cairo in September1994, was thethird UN-sponsored conference on population. The immediateresponses tothe conference, including the three Preparatory Com- mitteemeetings organised to encourage broad consultation, have ranged from highpraise for participants for laying a `pathto a betterreality’ , 75 todismissal ofthe new Population Plan of Action as emergingfrom a `misconceived’ 267 KELLEY LEE &GILL WALT internationalconference. 76 Manyargue that a globalconsensus has emerged.For example,Cassen arguesthat `there is agrowingconvergence of views¼ on the consequencesof rapid population growth in developing countries¼ and what shouldbe theprincipal elements of populationpolicy’ . 77 Othersbelieve that this consensushas beenwon by avoiding key sensitive issues andkeeping commit- mentsvague. Onesubject on which there has beenclearer agreement has beenthe concept ofreproductivehealth. While opinion has continuedto vary as tohow inclusive theconcept should be, 78 mostagree that reproductive health can be broadly de®ned as `a comprehensiveapproach to women’ s healthand wellbeing, that includesfertility and infertility, contraception, abortion, childbearing, maternal morbidityand mortality, sexuality, sexually transmitted diseases, menstruation andmenopause’ . 79 As Lanewrites, this holistic approach to population and fertilityhas arisenas areactionfrom women’ s organisations, 80 academic researchers (notablysocial scientists), and NGOsagainstthe long-established populationcontrol approach. Eschewing a viewof women focused on fertility andcontraceptive behaviour, this broad coalition of interest groups has effec- tivelyput reproductive health on national and international policy agendas. Institutionaladvocates of reproductive health include the UN PopulationFund, WorldHealth Organization, Ford Foundation, Population Council, International PlannedParenthood Federation ( IPPF),andUK Overseas DevelopmentAdminis- tration.81 Ithas beenthis global support for reproductive health which explains themost striking feature of the Cairo conference, the prominence of women as nationaldelegates and as representativesof NGOs. As are¯ection of the conference’s focuson women and their empowerment, an unprecedented one- thirdof the18 000delegates to the conference were women. Making a particu- larlylasting impact was NorwegianPrime Minister Gro Harlem Bruntland. 82 Theparticipation of the eight case studycountries at the Cairo conference generallyre¯ ected little change from policies held since the late 1980s. The governmentsof Thailand, Bangladesh, Zimbabwe, Zambia, Tunisia and Algeria remainedsupportive of FP intheir own countries. With the exception of Thailand,which has virtuallytaken over from donors (notably USAID) the ®nancingof policies and programmes, the remaining governments have sought greaterassistance fromdonors to reach policy objectives. For example, at meetingsof the Preparatory Committee, the Bangladesh delegation pointed ®rmlyto the need for `increased technical and ® nancialsupport’ from high-in- comecountries if serious efforts were to be made to carry out the new PopulationPlan of Action. 83 Similarlythe Algerian delegate strongly criticised some donorcountries for failing to `put their money where their mouth is’ , settingobjectives but offering too little to help meet them. Forthe Philippines and Pakistan, the objections of the Vatican and some Islamicgovernments (eg those of and Libya), did not prevent their support inprinciple for the Plan of Action. Particular attention was paidby theWestern mediato the speeches ofPrimeMinister Benazir Bhutto of Pakistanwho de® ed criticsat home by attending the conference. Declaring that she wouldnot allow `a vocal,narrow-minded minority to dictate an agenda of backwardness’ , she spokeof the problem of rapid population growth in Pakistan and called on the 268 NATIONAL AND GLOBAL POPULATION AGENDAS donorcommunity to provide increased assistance. 84 Inthe Philippines, public demonstrationsby the Catholic Church against abortion failed to deter the governmentfrom supporting the strengthening of FP policiesand programmes.

Conclusion Thispaper has analysedthe historical determinants of family planning policies andprogrammes in four pairs of developing countries. It was foundthat there has beena complexinteraction between policy context, process andactors. Usinga policyanalysis framework, comparisons were used to identify differ- ences inhow policies have been made and, in particular, whether global-level policymaking can in¯ uence why countries have had a weakeror stronger commitmentto FP. Policymaking at the global level can take many forms includinghigh-pro® le internationalconferences, low-key technical meetings and research onpopu- lationissues. Itwas foundthat, under certain circumstances, policy making at the globallevel can in¯ uence whether FP is placedon the policy agenda at the nationallevel. The degree of in¯ uence these activities exert has dependedon boththe political ideology of policyelites, and economic relations with Western countries.Where policy elites have been more open to Western ideas, FP has appearedearlier on national policy agendas. This ® ndingis bestsupported over theperiod of study by Algeria/ Tunisiaand Zambia/ Zimbabwe.In Algeria and Zambiabefore the 1980s, where there were unreceptive environments, strong anti-imperialistfeelings among political leaders placed a barrieragainst Western- ledefforts to promote FP atthe global level. Then, amid shifts in political ideologyfrom the early 1980s, global level activities (eg the Mexico conference) helpedmobilise increased national attention to FP. Inthe other two pairs of countries, differences in political economy are also usefulin explaining policy initiation, although less so forunderstanding how FP has faredat subsequent stages ofthe policy process (ieformulation and implementation).In Pakistan/ Bangladeshand the Philippines/ Thailand,close politicaland economic relations with the West during the 1960s were an importantcontributor to FP beingput on the policy agenda at an early date. However,beyond the identi® cation of FP asapolicyissue, close relations were insuf®cient to ensure that effective formulation and implementation of FP policieswere achieved. Stronger commitment to programmes occurred in Thai- landfrom the 1970s and Zimbabwe from the 1980s, but commitment weakened inthe Philippines and Pakistan. This difference suggests the need to consider domesticfactors (ie whether suf® cientresources weremade available to im- plementprogrammes) alongside global factors. Overall it can be concludedthat globalinitiatives can be aneffectivemeans ofin¯uencing national policy makers andputting issues onthe policy agenda, but this must take place within a receptivecontext of broader political and economic relations. Interestinglythe analysis did not ® ndabsolute level of economic development tobe related to the timing when FP appearedon national policy agendas. For example,rising oil revenues during the 1970s put Algeria on a muchstronger economicfooting than Tunisia. Yet Tunisian policy makers has demonstrateda 269 KELLEY LEE &GILL WALT consistentcommitment to FP fromthe 1960s. Similarly the Zambian government paidlittle attention to FP untilafter the boom years ofthe 1970s, while the Zimbabweangovernment gave immediate support to FP aftermany years ofwar withthe white Rhodesian government. It appearsthat commitment to FP has been strongerwhere policy makers havelinked economic development (regardless of itsabsolute level) with the need to limit population growth. In countries where thisargument was takenup by policy elites (eg Pakistan and Thailand in the 1960s)greater commitment to FP policiesand programmes can be found.Where thisargument was rejected(eg Zambia, Algeria), FP was keptoff the policy agenda.In short, it appears that sustained commitment to FP bypolicy makers has beenmore signi® cant in creating effective policies and programmes than a givenlevel of economic development.

Notes Theauthors would especially liketo thank Professor John Cleland and Louisiana Lush, Centre forPopulation Studies,London School of Hygiene and Tropical Medicine for their essential contributionto this work. 1 Itis estimated thatin 1991 international population assistance totalledUS$1.3 billion per year. The total currentannual expenditure on family planning by couples, government and donors is estimated at US$4.5 billion.See UN PopulationFund, GlobalPopulation Assistance Report, 1982± 1991 ,New York:UNFPA; andB Robey,S Rutstein& LMorris,`The fertility decline in developing countries’ , Scienti®c American , 269(6), 1993, pp 30± 37. 2 Theme-based conferences includethe UN Conferenceon Environment and Development (1992), World Summitfor Social Development (1995) and UN FourthWorld Conference on Women (1995). 3 Thereport of this study is KLee, GWalt,L Lush& JCleland, PopulationPolicies and Programmes: Determinantsand Consequences in Eight Developing Countries ,London:School of Hygiene and Tropical Medicine/UNFPA,June 1995. The authors of thispaper coordinated the policy analysis carried outby eight countrydirectors. This paper draws andbuilds on the resulting case studyreports which were as follows: ProfessorLedivina Carino, PopulationPolicy in the Philippines ,Collegeof Public Administration, Universityof the Philippines; Dr Kua Wongboonsin, PopulationPolicy and Programmes in Thailand , Director,Institute of Population Studies, Chulalongkorn University; Dr NebihaGueddana, Population Policiesand Programmes: Determinants and Consequences in Tunisia (1956± 1992), FormerSecretary of State tothe Prime Ministerin Charge of Women and Family Affairs; Dr AliKouaouci, The Algerian PopulationPolicy ,Directeur, Institutdes Sciences Sociales,Universite ÂdeBlida; Lumba Kalumba, Determinantsand Consequences of Population Policy and Programmes in Zambia ,Consultant;Leonard Maveneka, FamilyPlanning Policy Determinants: The Zimbabwe Case , Editor, SouthernAfrican Economist;Ayesha Khan, PopulationPolicies and Programmes in Pakistan ,Consultant;Dr Raisul Mahmood, Determinantsof Population Policies and Programmes in Bangladesh ,SeniorResearch Fellow, BangladeshInstitute of Development Studies. 4 Anobvious exception to this generalisation is Chinawhere, inthe early 1970s,vigorous promotion of FP begandespite relative isolationof the government from international pressures. See SConley& SCamp, China’sFamilyPlanning Program: Challenging the Myths ,Washington,DC: Population Crisis Committee, 1992. 5 Fora discussionof various development strategies, including`stages ofeconomic growth’ , dependency theoryand neoliberalism, see MTodaro,`The meaning of development’ in Economicsfor a developing world,London:Longman, 1992, Chapter 6. 6 PDemeny, `Populationpolicy and the international donor community: a perspectiveon the next decade’ , Populationand Development Review ,3(1),1977, pp 113± 122. 7 O Noman, ThePolitical 1947± 85 ,London:KPI, 1988, p 14. 8 Interviewwith Alamgir Kabir,Vice President(1960± 72) and President (1976) of the Family Planning Associationof Bangladesh, as quotedin Mahmood, Bangladesh, p 17. 9 ThePakistan Times ,25February 1959, as quotedin Khan, Pakistan, p 4. 10 These were theBulawayo Family Planning Association, created as alocaloffshoot of the Family Planning Associationof Great Britain,and the Salisbury Family Planning Association. 270 NATIONAL AND GLOBAL POPULATION AGENDAS

11 Maveneka, Zimbabwe, pp 2±3. 12 JFinkle& BCrane,`Ideology and politics at MexicoCity: the at the1984 International Conferenceon Population, Populationand Development Review ,11(1), 1985, pp 1± 28. 13 PDonaldson& ATsui,The International Family Planning Movement, PopulationBulletin ,45(3),1990, pp. 1±46. 14 JFinkle& CMcIntosh(eds), TheNew Politics of Population:Con¯ ict andConsensus in Family Planning , New York:Population Council, 1994, pp 6± 8. 15 Forexample see ACoale &EHoover, PopulationGrowth and Economic Development in Low-income Countries:A Case Studyof ’ sProspects ,Princeton,NJ: PrincetonUniversity Press, 1958. 16 Quotedin Gueddana, Tunisia, p 7. 17 C Patton, TheUnited Nations and the Politics of Population,1960± 1974 ,PhDthesis, New York:Columbia University,1984, p 57. 18 Kouaouci, Algeria, pp 6±7. 19 As quotedin ibid, p 14. 20 UNFPA, Zambia:Report of Mission on Needs Assessment forPopulation Assistance ,ReportNo 63, New York,1983, p 10. 21 M Burdette, Zambia:Between Two Worlds ,Boulder,CO: Westview,1988, pp 77± 80. 22 UNFPA, 1983, Zambia, p 13. 23 Kalumba, Zambia;andT Hopkins& RSiamwiza, `Convergingforces: processes leadingto the rethinking ofpopulationpolicy in Zambia’ inKOsei-Hwedie &MNdulo(eds), Issues inZambian Development , Zaire: Omenana, 1985,pp 72± 96. 24 JFinkle,`The political environment of populationcontrol in India and Pakistan’ in R Clinton,W Flash& RGodwin(eds), PoliticalScience inPopulation Studies ,Lexington,VA: LexingtonBooks, 1972, p 121. 25 Patton, TheUnited Nations and the politics of Population , pp 66±67. 26 TheAsian PopulationConference, held in New Delhiin 1963, was sponsoredby the UN Economic Commissionfor Asia andthe Far East ( ECAFE).Theconference was attendedby over 200 delegates from 14Asian countries. 27 Thepolicy of containmentwas basedon theperceived need in USforeign policy to establisha strategic dam againstthe spread of communism in such regions as SoutheastAsia andLatin America. Fora discussion see SHoffman, Primacy orWorld Order: AmericanForeign Policy Since the Cold War , New York: McGraw-Hill, 1978. 28 C Keyes, Thailand:Buddhist Kingdom as ModernNation-State ,Boulder,CO: Westview, 1989, pp 113± 114, 153. 29 J Goodno, ThePhilippines: Land of Broken Promises ,London:Zed, 1991, p 48. 30 Wongboonsin, Thailand, p 2. 31 Carino, Philippines , pp 3±5. 32 UNGeneral Assembly Resolution3201[XXIX], 1 May1974. 33 As quotedin Kouaouci, Algeria, p 13. 34 World Bank, WorldDevelopment Report ,Washington,DC: WorldBank, 1980, Table 16. 35 Gueddana, Tunisia, pp 23±24. 36 WRuf,`Tunisia: contemporary politics’ in R Lawless &AFindlay(eds), NorthAfrica: Contemporary Politicsand Economic Development ,London:Croom Helm, 1984,pp 107± 108. 37 MWest,`Nationalism, race, andgender: the politics of family planning in Zimbabwe, 1957± 1990,’ Social History ofMedicine ,7(3),1994, pp. 447± 471. 38 Burdette, Zambia, p 113. 39 Mahmood, Bangladesh, pp 24, 28. 40 `Populationmisconceptions,’ TheEconomist ,28May 1994, pp 121± 122. 41 UNFPA, Bangladesh:Report of the Second Mission on Needs Assessment forPopulation Assistance , New York: UNFPA,1986,pp 1, 8± 9. 42 Noman, ThePolitical Economy of Pakistan , p 91. 43 Khan, Pakistan, pp 12±14. 44 Noman, ThePolitical Economy of Pakistan ,pp61± 64, 86. 45 Keyes, Thailand,pp100± 114. 46 Wongboonsin, Thailand, p 17. 47 Goodno, ThePhilippines , pp 67±68. 48 W Stephen, Primary HealthCare inthe Arab World ,Wells:Somerset House,1992, p 28. 49 Algeria’ saidbudget peaked at 0.88%of GNP in1979 but by 1983had declined to 0.09% of GNP. See World Bank, WorldDevelopment Report ,Washington,DC: 1985,Table 16. 50 Finkle& Crane,`Ideology and politics at MexicoCity’ , p5. 51 Kouaouci, Algeria, p 24. 52 E Boohene, Establishmentof a Secretariatfor Population Policy and Development ,Reportto the Ministry ofHealth, Zimbabwe, 1988. 271 KELLEY LEE &GILL WALT

53 Maveneka, Zimbabwe, pp 23, 29. 54 In1984 copper prices were almost 60%lower than in 1974. Hopkins & Siamwiza, `Convergingforces’ ,p 75. 55 Burdette, Zambia,pp122± 127; and Hopkins & Siamwiza, `Convergingforces’ ,p75. 56 Burdette, Zambia,pp123, 156± 157. 57 World Bank, Accelerated Developmentin Sub-Saharan Africa: An Agenda for Action ,Washington,DC: 1981;World Bank, Zambia:Population, Health and Nutrition Sector Review ,Washington,DC: 1984;World Bank, WorldDevelopment Report ,Washington,DC: 1984; UNFPA, Zambia:Report of Mission on Needs Assessment forPopulation Assistance ,New York,1984. 58 Hopkins& Siamwiza, `Convergingforces’ ,p72. 59 Kalumba, Zambia, p 14. 60 `Theanswer’ satomato,’ TheEconomist ,20May 1994, p 86. 61 Donaldson& Tsui, TheInternational Family Planning Movement , p 37. 62 UNFPA, Thailand:Programme Review andStrategy Development Report , New York: UNFPA, 1991, p 12. 63 Wongboonsin, Thailand, p 17. 64 `Theanswer’ satomato,’p 86. 65 Carino, Philippines , p. 9. 66 Goodno, ThePhilippines , p 73. 67 Carino, Philippines , p 9. 68 R Sobhan, TheCrisis ofExternal Dependence: The Political Economy of Foreign Aid in Bangladesh , Dhaka:University Press, 1982,pp 20± 24. 69 UNFPA, 1986, Bangladesh, pp 8±9. 70 Sobhan, TheCrisis ofExternal Dependence , p 8. 71 Noman, ThePolitical Economy of Pakistan , p 174. 72 Sobhan, TheCrisis ofExternal Dependence ,pp166± 201. 73 Noman, ThePolitical Economy of Pakistan , p 174. 74 Khan, Pakistan, p 24. 75 Na® s Sadik, UNFPA ExecutiveDirector, Cairo, 1994. 76 AHamilton,`Population is notthe agenda,’ Observer,11September 1994, p 25. 77 R Cassen, PopulationPolicy: A New Consensus ,Washington,DC: Overseas DevelopmentCouncil, 1994, pp 66±67. 78 TheUK Overseas DevelopmentAdministration, for example, de®nes reproductivehealth as `making pregnancyand childbirth safer, preventingand treating infections of thereproductive system (including HIV infection),helping infertile couples and reducing the incidence of genital mutilation’ . See LChalker, `Childrenby choice not chance,’ Speechto the Royal Society, London, 11 July 1994. 79 SLane,`From population control to reproductive health: an emerging policy agenda,’ SocialScience and Medicine,39(9), 1994, pp 1303± 1314. 80 Thesupport of manywomen’ s organisationsled to theWomen’ s Declaration onPopulationPolicies of 1994 bythe International Women’ s Health Coalitionbased in New York. 81 Itis interestingto note that UNICEF continuesto use theconcept of `safe motherhoodand family planning’ tode® ne its activities. This differs from reproductive health in its narrower focus on maternal andchild health,its avoidance of abortion-related activities, and its emphasis on`birth spacing’ as opposedto `birth control’. See UNICEF, AnnualReport ,New York,1994. 82 LO’Hanlon,`Too big for her roots,’ Independent ,11September 1994. 83 Quotedin S Johnson, WorldPopulationÐ Turning the Tide: Three Decades ofProgress ,London:Graham &Trotman,1994, p 358. 84 Quotedin D Willey,`Women take thelead inCairo battle of sexes,’ Observer,11September 1994.

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