5 Human development issues and policies

This chapter looks at the four mainareas of human developmenteducation, health, nutrition andfertilityand at the links betweenthem. In each, it considers thecauses and effects of poverty andvarious ways of breaking its gripon the poor and their children.

Ten years ago this chapter wouldhave been written very different-ly. In certain areas thinking haschanged substantiallyfor instance,about the nature of malnutritionand its causes. Good progress hasbeen made in unraveling somecomplex and highly controversialissuesfor example, the respec-tive roles of family planning andsocial development in reducingfertility. And in all areas, researchand practical experience have im-proved understanding of the na-ture of poverty and what can bedone about it.

Education

Every individual is born with acollection of abilities and talents.Education, in its many forms, hasthe potential to help fulfill andapply them.

In some societies the economicfunction of schooling is regardedas minorsince the cultivation ofthe mind and the spirit, curiosity,contemplation and reasoning havemore than economic purposes andjustifications. But in the contextof this Report, it is the role of edu-cation in overcoming povertyincreasing incomes, improvinghealth and nutrition, reducing

46

family sizethat receives mostattention.

A decade or two ago, there wasa widespread view that trainedpeople were the key to develop-ment. Universal literacy was apolitical objective in many coun-tries, but money spent on primaryschooling was often regarded asdiverted from activities that wouldhave contributed more to economicgrowth. Planners favored the kindsof secondary and higher educationthat directly met the "manpowerrequirements" of the modernsector. People who worked withtheir hands were thought notto have much need of formaleducation.

Over the past decade, viewshave changed substantially. Ade-quate provision of secondary andhigher education and trainingremains an important priority. Butthe value of general education atthe primary level is now morewidely recognized. This sectiondiscusses more of the evidencethat lies behind this change in

Table 5.1 Public expenditures on elementary and higher educationper student, 1976

views, and its implications fordevelopment strategy.

Recent progress

The major educational progressof the past two decades reflectsheavy investment by developingcountries. Their total publicexpenditure on education rose inreal terms (in 1976 dollars) fromabout $9 billion in 1960 (2.4 per-cent of their collective GNP) to$38 billion in 1976 (4.0 percent ofGNP). Costs vary widely byregionand by type of education(see Table 5.1). The potential forcontinued enrollment growth atdifferent levels will, of course, bestrongly affected by these costs.

But school attendance in someparts of the world remains low,especially among the poor, in ruralareas and by girls (see Figure 5.1and Table 5.2). This is not simplybecause schools are unavailablenot everyone who has an oppor-tunity for education accepts it.Among those who do enroll, more-over, in developing countries on

Note: Figures shown are averages (weighted by enrollment) of costs (in 1976 dollars) in thecountries in each region for which data were available.

Region

Higher (post-secondary)education

Elementaryeducation

Ratio of higher toelementary education

Sub-Saharan Africa 3,819 38 100.5South Asia 117 13 9.0East Asia 471 54 8.7Middle East and North Africa 3,106 181 17.2Latin America and Caribbean 733 91 8.1Industrialized 2,278 1,157 2.0USSR and Eastern Europe 957 539 1.8

average 40 percent drop out beforethe fourth year. In Brazil's poorrural Northeast region in 1974,despite an enrollment rate of 46

Figure 5.1 Enrollment ratios, by region, 1960-75(percent)

Middle East Latin Sub-Saharanand North Africa South Asia East Asia America Africa

UNESCO.

Table 5.2 Primary school enrollment, by income group(percent)

Poorest RichestCountry households households

Sri Lanka, 1969-70

Nepal, 1973-7411 towns

India: Gujaratstate, 1972-73

RuralUrban

India: Maharashtrastate, 1972-73

RuralUrban

Colombia, 1974

Large citiesAll urbanRural

Boys (aged 5-9)

percent (less than half the nationalurban average), nearly two-thirdsof the students dropped out beforethe second year-and it is estimated

Both sexes (aged 6-71)

Poorest Richesthouseholds households

Girls (aged 5-9)

Poorest Richesthouseholds households

Note: Enrollments are expressed as a percentage of the number in the age group. Poorestand richest refer (in the case of India, Nepal and Sri Lanka) to the bottom and top 10 percentof households ranked by expenditure per person, and (in the case of Colombia) to the topand bottom 20 percent of households ranked by income per person.

that at most 4 percent completedfour years. Even the completionstatistics conceal the very lowquality of some of the schoolingprovided (see pages 52-53).

Nonetheless, the very substantialgrowth in enrollment (Figure 5.1)is a sign of great educational advance.There are several mechanismsthrough which this has contributedto growth in incomes.

Effects of education on earning power

Schooling imparts specific knowl-edge and develops general reasoningskills (its "cognitive" effects); italso induces changes in beliefs andvalues, and in attitudes towardwork and society ("noncognitive"effects). The relative importanceof these effects is much debated,but poorly understood; both areextremely important.

In the cognitive area, developinga generalized capacity for thinkingand learning has to be found to bemore important than the specificsubjects learned. On-the-jobtraining, informal education andvocational training all build onlearning abilities acquired earlier.And although literacy and num-eracy deteriorate if left unused, theeducational experience still gen-erally provides an improved foun-dation for subsequent learning.

Many of the noncognitive effectsof schooling-receptivity to newideas, competitiveness, and will-ingness to accept discipline-aredirectly relevant to productiveeconomic activity. Others-toler-ance, self-confidence, social andcivic responsibility - are morepersonal or political in nature,but may also affect economicperformance.

Some of the evidence on theeffects of education rests on at-tempts to measure attitudes directly.Studies in several countries haveshown that "modernity" of outlooktoward activities ranging from vot-ing to family planning, saving and

47

Female (6-11)

Male (6-11)Male (6-11)

Male (6-11)

Male (6_Il)Female (6-11)

Male (12-17)

Female (6-11)Male (6-11)

- Male (12-17)Female (6-11)

/ZMale (12-17) Male (12-17)Female (12-17)

Female (12-17) Female (6-11)Female (12-17)

Ml (1823) Ml (1217)

M 1 (18 23)Female (12-17)

M Ic (28 23)Female (12-17)

Male (18-23) Female (18-23)

F m I (18 23) 823)

'60 65 70 75 60 65 70 75 60 65 70 75 60 65 70 75 60 65 70 75

69.6 94.662.0 89.551.2 60.0

70.3 89.8 65.8 81.9

29.5 77.8 15.3 71.2

22.7 53.9 8.6 50.942.1 77.7 30.8 69.5

24.6 54.6 16.6 52.940.4 86.3 42.1 87.0

80

70

60

50

40

30

20

10

0

I

working, is more influenced by thelevel of the individual's schoolingthan by any other factor. But thereare also many studies of the directeffect of schooling on individualproductivity and earnings, whichare examined here under two headsthose relating to the self-employedand those relating to employees.

THE SELF-EMPLOYED. The hy-potheses are straightforward: thatprimary education helps people toobtain and evaluate informationabout improved techniques andnew opportunities, to keep recordsand estimate the returns of pastactivities and the risks of futureones. More generally, primaryschooling is a training in how tolearn, an experience in self-discipline and in working forlonger-term goals.

Most of the empirical evidencecomes from agriculture - studiescomparing the productivity, yieldsand innovative activity of schooledand unschooled farmers. Not allthese studies controlled adequatelyfor other influences, particularlywealth; but many did (for example,by including farm size as a proxyfor wealth).

The general weight of the evi-dence (see Table 5.3) lends strongand consistent support to thehypothesesand is particularlycompelling because the studiesmeasure productivity directly, notthrough wages. Where the com-plementary inputs required forimproved farming techniques wereavailable, the annual output of afarmer who had completed fouryears of primary schooling wason average 13.2 percent more thanone who had not been to school.As expected, where complementaryinputs were not available, the in-crease in output resulting fromadditional schooling was on aver-age smallerbut still substantial.

Whether these increases shouldbe regarded as large or small de-

48

Table 5.3 Farmer educationand farmer productivity

With complementary inputs'Brazil (Garibaldi), 1970 18.4Brazil (Resende), 1969 4.0Brazil (Taquari), 1970 22.1Brazil (Vicosa), 1969 9.3Colombia (Chinchina),

1969 0.8Colombia (Espinal), 1969 24.4Kenya, 1971-72 6.9Malaysia, 1973 20.4Nepal (wheat), 1968-69 20.4South Korea, 1973 9.1

Average (unweighted) 13.2

Without complementary inputsBrazil (Candelaria), 1970 10.8Brazil (Conceicao de

Castelo), 1969 3.6Brazil (Guarani), 1970 6.0Brazil (Paracatu), 1969 7.2Colombia (Malaga), 1969 12.4Colombia (Moniquira),

1969 12.5Greece, 1963 25.9

Average (unweighted) 8.1

No information on availabilityof complementary inputs

Average of eightstudies (unweighted) 6.3

a. Improved seeds, irrigation, transportto markets and so on.

pends on the cost of achievingthem. It is thus significant thatstudies that went on to comparethe increase in production result-ing from education with the costsof that education (for example, inKorea, Malaysia and Thailand)found rates of return comparingvery favorably with investment inother sectors. It is, of course, im-possible to predict which placeswill offer scope for improved farm-ing techniques in 10 years' time,when children leave school. Insome, effects on farm productivitymay be low. But given past progressin agricultural research, it is prob-able that some places with stagnanttechnology now will offer greatlyimproved possibilities. Thus, ongrowth as well as equity grounds,

it would be short-sighted to leavea large part of the next generationof farmers illiterate.

EMPLOYEES. The second type ofstudy relates the educational levelsof individuals to their wages andsalaries. If education affects thecapacity to learn, innovate andadapt, its effects should be par-ticularly important for employeesdoing nonroutine or changingtasks. For employees in modernenterprises, primary education alsopromotes disciplined work habitsand responsiveness to furthertraining, as well as offering the ad-vantages of literacy and numeracy.

Studies of the rate of return toeducation for wage earners dealmainly with relatively large urbanenterprises; but a few have in-cluded small businesses and agri-cultural workers. All find thatmore schooling leads to higherearnings. And when the extra earn-ings resulting from primary educa-tion are weighed against its costs,high rates of return are consistentlyfound. Similar studies for secondaryand higher education find lower,though nonetheless substantial,returns (see Table 5.4 and box).

Investment priorities in education

Primary education is of particularimportance in overcoming absolutepoverty. But secondary, higher,vocational and adult educationand training also have major rolesto play.

PRIMARY EDUCATION. In coun-tries where it is far from universal,the case for increasing the propor-tion of children who complete pri-mary education is strong. Whilethere have been high economicreturns in the past, it has beensuggested that the rate of return toprimary schooling (especially incertain jobs) may decline as theproportion of the labor force withprimary education increases. But

Estimated percentageincrease in

annual farm outputdue to four years

of primary educationStudy rather than none

this may be offset by shifts in thepattern of production toward moreskill-intensive goods. In Table 5.4the rates of return to primaryeducation in countries with adultliteracy rates above 50 percent,while somewhat below those incountries with adult literacy below50 percent, are still strikingly high.

And in the few countries wherestudies have been done at differ-ent periods, rates of return haveusually declined, but only mildly.

There are also favorable effectson equity. As primary educationbecomes more widespread, addi-tional spending will be increas-ingly concentrated on backward

Note: In all cases, the figures are "social" rates of return: the costs include forgone earnings(what the students could have earned had they not been in school) as well as both publicand private outlays; the benefits are measured by income before tax. (The "private"returns to individuals exclude public costs and taxes, and are usually larger.) The studiesrefer to various years between 1957 and 1978, mainly in the latter half of the period.a. In this sample of 30 developing countries, those countries with low incomes also hadliteracy rates below 50 percent (at the time the studies were done). All the middle-incomecountries had literacy rates above 50 percent.

Schooling, screening and productivity

The interpretation of rates of returnto educationespecially secondary andhigher educationis still controversial. Ithas often been argued that educationalqualifications are simply a "screening"device, signaling an individual's produc-tive qualities to an employer withoutactually enhancing them. In somedeveloping countries, moreover, thepublic sectorand some heavily protectedparts of the private sectorare the mainemployers of university and even second-ary-school graduates: it has been sug-gested that the salaries they pay are oftenartificially inflated and bear little relationto relative productivity; and that educa-tional requirements serve merely to rationaccess to these inflated salaries. In bothcases, earnings differences associatedwith different levels of education wouldoverstate the effect of education onproductivity.

On the other side, it is argued thatschool "screening" is by no means allwasteful and is preferable to such otherscreening methods as caste or familyconnections. It is also argued that labormarkets are not so monopolistic, and

thus that relative wages are not suchimperfect indicators of productivity, asthose who have concentrated on theirinstitutional characteristics and determi-nants have supposed. In developedcountries the relative wages of differentoccupations have gradually but steadilychanged in response to increases in thesupply of educated labor. That the sameprocess operates even in the public sectorin developing countries is suggested, forexample, by the fact that the relativesalaries of teachers and civil servantsace much higher in Africa, where edu-cated manpower is much scarcer, thanin Asia, where it is more abundant.

The conventional economic interpre-tation of the association between school-ing and wages is further strengthened bya few studies showing that more educatedworkers have increased output in specificmanufacturing industries, by evidenceof substantial returns to education evenin agriculture and other traditional small-scale activities, where one would expecteducational credentials to be much lessimportant, and by the macroeconomicevidence discussed in the box on page 38.

rural areas, girls, and the pooresturban boys. In general, primaryeducation tends to be redistribu-tive toward the poor (see Table5.5). In contrast, public expendi-ture on secondary and highereducation tends to redistributeincome from poor to rich, sincechildren of poor parents havecomparatively little opportunityto benefit from it.

Primary education, especially ofgirls, has favorable effects on thenext generation's health, fertilityand education (see box overleaf).Finally, it enriches peoples' lives.Many would regard this as suffici-ent justification for universal pri-mary education, independent ofits other benefits.

sEcoNDARy AND HIGHER EDucATIoN.

Renewed emphasis on the impor-tance of primary education, andits high returns relative to sec-ondary and higher education,should not start the pendulumswinging too far in the other di-rection. High levels of knowledgeare necessary for many people whoserve the poor, both directly asteachers, health workers and agri-cultural extension workers, andindirectly as researchers, techni-cians, managers and administrators.While their skills must be developedto a considerable extent throughpractical experience and in otherways, there is for some purposesno better or cheaper substitute forthe formal disciplines of conven-tional schooling. Even allowing fordoubts about the estimated ratesof return to secondary and highereducation, and for the existenceof some educated unemployment(see box on next page), there areunquestionably severe shortagesof skilled people in many developingcountries.

More economical ways of pro-ducing skilled people need to befound. First, greater use of in-careerand on-the-job training should be

49

Table 5.4 Rates of return to education(percent)

Number ofCountry group Prim ary Secondary Higher countries

All developing countries 24.2 15.4 12.3 30Low income/adult literacy

rate under 50 percent' 27.3 17.2 12.1 11Middle income/adult literacy

rate over 50 percent 22.2 14.3 12.4 19Industrialized countries 10.0 9.1 14

Households ranked by income per person.Federal costs per household.Subsidies per household.

explored. Second, steps should betaken to reduce the high unit costsof secondary and higher education(shown in Table 5.1).

For example, the number ofuniversity specializations can bereduced, relying on foreign uni-versities (not necessarily in devel-oped countries) for specializedtraining in areas in which smallnumbers of students lead to ex-cessive teaching and equipment

50

Primary University

The benefits of women's educationEducating girls may be one of the bestinvestments a countiy can make in futureeconomic growth and welfareeven ifgirls never enter the labor force. Mostgirls become mothers, and their influencemuch more than the father'son theirchildren is crucial:

In health. Studies in Bangladesh,Kenya and Colombia show that childrenare less likely to die, the more educatedtheir mothers, even allowing for differ-ences in family income.

In nutrition. Among householdssurveyed in Sao Paulo, Brazil, for anygiven income level, families were betterfed the higher the mother's education.

In fertility. Education delays mar-riage for women, partly by increasingtheir chances of employment; and edu-cated women are more likely to knowabout, and use, contraceptives.

Yet in most parts of the developingworld, there are many more boys thangirls enrolled at school (see Figure 5.1).True, female enrollment grew faster thanmale between 1960 and 1977; but whenboys' enrollments were where femaleenrollments are today, they were grow-ing even faster. The educational bias ismost pronounced in South Asia, theMiddle East and North Africa, and parts

of Sub-Saharan Africa; but it exists tosome extent in every region.

Why? From the parents' point of view,education for their daughters may seemless attractive than for their Sons. Theymay fear that education will harm theirdaughters' marriage prospects, subsequentdomestic life and even spiritual qualities.A girl's education brings fewer economicbenefits if there is discrimination againsther in the labor market, if she marriesearly and stops working or if she ceasesafter marriage to have any economicobligations toward her parents.

But parents md their daughters dorespond rapidly to changing opportunities.When women took on key roles in theAnand Dairy Cooperative in Gujarat,India, education for girls became morevalued. When a nutrition project inGuatemala offered employment to edu-cated girls, the test scores of youngergirls improved.

More generally, education does increasethe chance of paid employment for girls.In Brazil married women with secondaryeducation are three to four times morelikely to be employed than those withprimary education onlywho in turn aretwice as likely to work as women withno education at all.

costs per student. Care must betaken to encourage repatriationand to prevent foreign trainingfrom becoming exclusively theprivilege of the children of therich and influential.

Correspondence courses candramatically reduce the cost ofsecondary and higher educationand teacher training. The KoreanAir-Correspondence High School,for example, provides secondary

education at about a fifth the costof traditional schools, and allowswould-be students who have toearn a living to continue their edu-cation at the same time. Recentstudies (in Brazil, Kenya and theDominican Republic) have alsoconcluded that correspondencecourses have effectively taughtpeople in remote areas.

In most countries the familiesof postprimary students pay toolittle for education. They are gen-erally much better off than thenational average: in Tunisia, forexample, the proportion of chil-dren from higher income groupsis nine times larger in universitiesthan in elementary school. Sincethe rewards from higher educa-tion are large, it is highly desirable(though often politically difficult)to charge tuition and other fees tocover costs. Scholarships can begiven to students whose familiescannot afford to pay.

The cost of secondary and highereducation makes it inevitable thatin most courthies demand for placeswill exceed supply for the fore-seeable future, although somecountries, such as South Korea,already have very high enrollmentrates. But economic considerationsare not the only relevant ones:secondary education often helps inlowering fertility and reducingchild mortality (over and abovethe effects of primary education).All developed countries havefound universal free secondaryeducation to be desirable in itsown right. The question for devel-oping countries is less "whether"than "when." Higher educationclearly also has scientific, culturaland intellectual objectives, as wellas economic ones.

VOCATIONAL EDUCATION AND TRAIN-

ING. Experience shows that it isoften inefficient to rely heavily onschools (as opposed to the work-place and short-term training

Income groap Primary Postsecondary

Poorest 20 percent 135 4 48 1Richest 20 percent 45 63 9 46

Table 5.5 Public education spending per household,by income group(dollars)

Malaysia, 1974b Colombia, 1974'

Unemployment among the educated

Unemployment statistics in developingcountries are sparse and often hard tointerpret. Evidence on open unemploy-ment (persons without a job and activelyseeking employment) indicates that it isprimarily an urban phenomenon heavilyconcentrated among workers in theirteens and early twenties. Since these arethe ages at which individuals typicallyleave school or university, there has beenconcern that educational expansion indeveloping countries will produce a grow-ing problem of "educated unemploy-ment." But despite the increased outflowof students over the past decade, partic-ularly secondary-school graduates, thereis no evidence of rising trends in openunemployment rates. Unemploymentstatistics from a number of countries do,however, suggest that secondary-schoolleavers experience higher rates of unem-ployment than the uneducated or thosewith postsecondary education.

By and large, educated unemploymentappears to be associated with the processesthrough which the labor market adjuststo an increased supply of school leavers.First, the earnings expectations or jobpreferences of school leavers may notkeep pace with changes in labor marketconditions brought about by increasednumbers of workers with educationalcredentials. Second, the structure of wagesmay be slow to adjustespecially if thepublic sector is a major employer ofeducated workers. School leavers maythen be encouraged to wait for jobs inwell-paid occupations rather than imme-diately accept a job that pays significantlyless; if the wage difference is high enoughand the probability of obtaining a higher-

paid job is sufficiently large, a period ofjob-seeking or unemployment will yielda higher expected "lifetime" income.

The educational pattern of unemploy-ment is consistent with this explanation.It is not worthwhile for uneducatedworkers to remain unemployed as theysearch for a well-paid job. At the otherextreme, highly trained people are scarcein many countriesso college graduatescan get well-paid jobs immediately. Butthose in betweenthe secondary-schoolleaversare neither assured of high-wagejobs nor completely out of the running;for them, there may be high returns toa full-time search for a job. Since theunemployed are young, with few depen-dents and often supported by their families,and since most of them eventually findjobs, neither the social nor the privatecosts associated with this unemploymentare as serious as might appear.

Moreover, the fact that some primary-and secondary-school leavers are unem-ployed does not imply that the economyis unable to make productive use of moreof them. Various studies have shownthat the social rate of return to investmentin education may be high despite thenumber of educated unemployed. Butin the eyes of governments, frustratedschool leavers or college graduates canform a politically volatile group. Somegovernments have therefore virtuallyguaranteed public-sector jobs for post-secondary leavers whether or not therehas been socially productive work forthem to do. This can result in a majordrain on government revenues and impedethe diffusion of educated manpower intomore productive uses as well.

institutions) to develop vocationalskills. Vocational and technicalschools often find it difficult tostrike the right balance betweengeneral preemployment trainingand the provision of specializedskills, and are often slow to adjustto the economy's changing needs.In many school systems wherecompetition for higher educationis strong, they also suffer from lowprestige.

By contrast, institutions thatprovide training in skills with wideapplicability as a foundation for

later on-the-job training or short-term courses (which may be neededmore than once in a lifetime) aremore likely to be successful, espe-cially if, as in Brazil, Chile andSingapore, there is coordinationwith potential employers.

ADULT EDUCATION. Certaintypes of adult education play auseful role. To be effective, adulteducation must be conducted bydedicated and responsible teachers,and must address specific, feltneeds; after a major review,

UNESCO concluded that the poorresults of most adult literacyprograms were due to lack ofdemand. Where there is an explicitneed, results have been better. Forexample, a recent review foundthat agricultural extensionwhichis essentially an applied form ofadult educationgenerally helpedto raise productivity; and theWorld Bank's experience withthe "training and visit" (T & V)approach to agricultural exten-sion, which puts great weight oncareful training and supervisionof field workers, is consistent withthis. In West Bengal, for example,T & V was introduced in 1975 andhelped to raise the proportion ofland area planted with high-yielding wheat and paddy varietiesfrom less than 2 percent to 40percent, in a single year. WhileT & V is effective even with illit-erates, literate farmers tend to bemore responsive to suggestedchanges.

Implementing investment priorities

The education received by poorchildren depends on three things.The first is accessibilityare thereschool places for them within areasonable distance from home?The second is usedo their par-ents send them to school, and arethey allowed or encouraged todrop out? The third concerns thequality of the education thatschools provide.

ACCESSIBILITY. Financing con-straints will often be compoundedby difficulties in reaching the poordistance, low-density popula-tions and poor communicationsso that building schools andsupplying books, equipment andqualified teachers is a difficult andexpensive task. For example, theNepalese government estimatesthat it costs more than twice asmuch to build and equip a schoolin mountainous regions as it does

51

in the plains; and attracting quali-fied teachers to remote areas hasproved to be extremely difficult.

There is often much that can beaccomplished by administrativeaction with relatively little capitalinvestment. Repetition of classesand early dropout may be theresult of excessively high promo-tion standards. In these circum-stances, the flow of students canbe accelerated by more automaticpromotionwhile maintainingquality by correcting some of thecauses of repetition or dropout.In many situations, resources canbe freed for extending educationby raising student-teacher ratios,which are the main determinantof unit costs (given teacher salaries)and are largely determined byclass size. Extensive research showsthat class size has surprisingly littleeffect on learning (see box). It isimportant to maximize the use ofavailable facilitiesby rotatingclasses, with staggered schedulingand double shifts in areas of highpopulation density. If there arenot enough pupils within anacceptable distance from school tofill individual classes, student-teacher ratios and the use of spacecan be significantly improved bytaking new students only in alter-nate years (as has been done suc-cessfully in a project financed by theWorld Bank in Malaysia) and byteaching more than one grade in aclass, as in another World Bank-financed project in El Salvador.

USE. Since most poor parentsbelieve that education wouldbenefit their childrenin terms ofstatus and the ability to stand upto officials and merchants, as wellas in a more narrowly economicsensethey must have strong rea-sons for not sending their childrento school if they have the chance.They may question whether theywill benefit themselves; they mayeven regard the school as a threat

52

Big is not necessarily badClass sizes vary widely in the developingworldat elementary schools, frommore than 60 in four countries (Chad,Malawi, Congo-Brazzaville and CentralAfrican Republic) to less than 25 inseven (Iraq, Barbados, Bolivia, Uruguay,Romania, Mauritania and Mauritius).Yet once classes have more than 40students, varying their size has almostno effect on student learning (thoughlarger classes may weaken disciplineand teacher morale). Between 15 and40, students learn more in smallerclasses (and still more in even smallerclasses), but the benefits are slight. Forexample, reducing an elementary-schoolclass from 40 pupils to 15 can beexpected to improve average achieve-ment (in a standard test) by only about5 percentage points. By the same token,a modest increasefrom 35 to 40 pupils,saymight reduce achievement by onlya single percentage point. While thereare obvious practical limits to increasingclasses much above 50, the researchdoes suggest that, for classes initiallybelow 50, little will be lost if they areincreased.

In sparsely populated areas, largerclassesif that means fewer schoolsmay increase the time it takes childrento get to school. That could be a genuinediscouragement, though in most placespopulation density is high enough notto make it so

to their traditional way of life; orthey may simply believe that socialor ethnic barriers are too great, orthe quality of the available school-ing too low, to make educationworth its costs. For poor families,the help of children at homeinanimal care, fetching fuel andwater, taking care of young chil-dren while adults work, and inagricultural work during busyseasonsmay conflict with a fixedschool schedule. For some families,malnutrition and poor health ofchildren may lead to poor atten-dance, inattention while in school,repetition of grades and, even-tually, dropping out. And there areparticular reasons that girls receive

less education than boys (see boxon page 50). Since the mere exis-tence of a school does not auto-matically mean it is used by allthose eligible to attend, specialmeasures may be needed to en-sure that the education offered isattractive to the families for whomit is intended (see pages 78-79).

QUALITY OF EDUCATION. This isgenerally low in developing coun-tries, and has been found (forexample, in studies undertaken inThailand, Malaysia and the Philip-pines) to be lower still for poorand rural pupils. Poor qualitypublic schools may lead the well-to-do to choose private schoolsfor their children, reinforcingsocial and economic inequality.

Casual observation and small-scale studies have long suggestedthat poor training of teachers, lackof textbooks, and inadequate schoolfacilities lead to poor educationalresults and provide a weak basisfor subsequent training. But broad-based evidence to demonstratethe extent of the resulting learninglosses has only recently becomeavailablefrom a large researchproject, the International Evaluationof Educational Achievement. Butonly four developing countries(Chile, India, Iran and Thailand)were among the 19 countriescovered.

While international compar-isons of student achievement mustbe approached gingerly, particu-larly when different languages ortesting styles can affect the results,a clear pattern nonetheless emergesfrom the study. Differences inaverage performance of studentsfrom the 15 developed countriesvaried somewhat from subject tosubject and country to country;but the differences by and largewere small. The developing coun-tries, however, did far less wellin all subjects tested, and at eachof the three age levels examined.

A typical finding showed the meanscore for students in a developingcountry to be in the bottom 5 to10 percent of students from adeveloped country. Some of thehandicaps of children in develop-ing countries may be due to lowerlevels of parental education (whichhas a substantial impact, particu-larly in the preschool years) orin some cases to prolonged mal-nutrition. But the evidence suggeststhat they are mainly a reflection oflow-quality schooling.

There are a number of promisingapproaches to improving education-al quality in developing countries.

The curriculum should takeinto account the linguistic andhome backgrounds of students.Frequently curricula are too de-manding, which only exacerbatestendencies to repeat classes ordrop out, particularly for thosefrom poor homes. Wheneverpossible, subjects should beillustrated with examples thatdraw on the child's experience.

The selection and training ofteachers should be improvedthrough more training facilities,greater use of in-service training,and more resourcesteachers'guides, advisory services, mass-media programs and bulletins. Thistakes time, however; for manycountries, better teaching will beas much a consequence as a sourceof improved quality in schools.

The design, production anddistribution of learning materialsshould be upgraded. This appliesparticularly to textbooks, becauseresearch indicates that increasingtheir availability is the most con-sistently effective way of raisingeducational standards. A nation-wide textbook project supportedby the World Bank in the Philip-pines significantly increased stu-dent learning while increasingcosts per student by only 1 per-cent. When school budgets aresqueezed, it is all too easy to cut

or defer spending on learningmaterials. But this is a costlyalternative if costs are consideredin terms of the education providedrather than simply per studentin school.

Properly designed and sup-ported radio projects have poten-tial for improving learning (and incertain cases reducing costs). Totake a well-documented example,in Nicaragua regular radio broad-casts achieved dramatic improve-ments in mathematics for primarystudents. Although new tech-nologies and growing experienceare increasing the educationalpotential of television, lack of ruralelectricity and the high costs ofcapital, maintenance and operationput it out of reach for most countries.

Research into these approacheshas indicated important potential,but it remains to be seen howmuch they can improve qualitywithin the constraints of politicallyfeasible budgets. This underlinesthe importance of finding cheapways to improve quality if theeducational gaps between devel-oping and developed countries, andbetween rich and poor in develop-ing countries, are to be narrowed.

Health

In general terms, the determinantsof health have long been well known.One is people's purchasing power(which depends on their incomesand on prices) over certain goodsand services, including food,housing, fuel, soap, water andmedical services. Another isthe health environmentclimate,standards of public sanitation andthe prevalence of communicablediseases. A third is people'sunderstanding of nutrition, healthand hygiene.

Knowledge is still evolving,however, on the relative importanceof these different factors, and onthe best ways to deploy government

resources to improve health. Bythe end of the 1960s it was increas-ingly plain that health care systemsmodeled on those in the developedworld were not the quickest,cheapest or most effective way toimprove the health of the majorityof people in developing countries.The 1970s have thus witnessedthe evolution of a much broaderapproach to health policy, indudingan emphasis on universal low-costbasic health care. But despite somesuccessful experiments, "primaryhealth care" is still more of aslogan than a nationwide realityin most developing countries. Tochange this is the greatest healthchallenge of the 1980s.

Life expectancy and mortality

There is considerable variationamong developing countries. In11 of the richer ones, life expectancyis 70 years or moreclose to theaverage level (74 years) in indus-trialized countries. But in low-income countries, life expectancyaverages only 50 years, and severalcountries are under 45. Thusdespite the health improvementsthat have occurred throughout thedeveloping world over the pastthree decades, the gap betweendeveloped and developing coun-tries remains wide.

Babies born in a developingcountry will on average live 20years less than those born in theindustrialized world. About halfof this difference can be explainedby what happens in the first fiveyears of life. Some 17 percent ofchildren in developing countries(and more than 30 percent inseveral of the poorest) die beforetheir fifth birthday; in industriali7edcountries, only about 2 percentdo. Mortality rates among childrenaged one to four in low-incomecountries are frequently 20-30times those in industrialized coun-tries, and sometimes even more.Although the gap tends to narrow

53

as average incomes rise, in anumber of countries with 1978incomes of more than $900 (in-cluding Jordan, Turkey, Algeriaand Guatemala) the chances of achild dying between its first andfifth birthdays were still at least10 times as great as in industrializedcountries. On average, for childrenin developing countries who reachthe age of five, further life expect-ancy is still eight to nine years

Figure 5.2 Death by age groups:developing and industrializedcountries, 1980

Percentage dead by the age of:5 15 50 65 over 65

Deaths by age group aspercentage of total deaths:

under 5 5-14 15-49 50-64 65 and over

less than in developed countriesand they are much more likely tosuffer from disease (see next page).

The very high death rates amongyoung children, combined withhigh birth rates, mean that atragically large proportion of thedeaths in a developing countryoccur among children under five(see Figure 5.2). For example, inBrazil in 1975 they were 48 percentof all deaths. In Sweden they were

54

Developing

Industrialized

1 percent. The main causes of childdeaths in developing countries arediarrheal diseases and respiratoryinfections, especially influenza andpneumonia. (It has been estimatedthat diarrheal diseases cause 5-10million deaths a year and respira-tory diseases 4-5 million, makingthem by far the biggest killers forthe population as a whole.)

Other diseases that make adultsill may be fatal in young children.Malaria, for example, has beenestimated to kill 1 million Africanchildren a year. Common childhooddiseases, such as measles, diphtheria,whooping cough and polio, whichhave either been virtually eliminatedfrom developed countries or elsereduced to minor nuisances, canbe fatal or crippling in developingones. A case of measles is oftenmore than 200 times more likelyto kill a child in a developing countrythan in an industrialized one. Allof these diseases can be preventedby vaccination, yet fewer than 10percent of the children born eachyear in the developing countriesare being protected.

A major reason that theseinfections so often lead to deathin preschool children in developingcountries is their interaction withmalnutrition, especially amongchildren between six months andthree years old. As a result, malnu-trition appears to contribute tobetween one-third and two-thirdsof all child deaths, and perhapseven more in the poorest countries.A comprehensive study of 35,000deaths in 14 communities in LatinAmerica found that 34 percent ofdeaths of children under five hadserious malnutrition as an under-lying or associated cause. Anadditional 23 percent of deathswere associated with prematurebirths, which themselves partiallyreflected maternal malnutrition.

Compared with children, adultmortality patterns in developingcountries show a much greater

similarity to those in developedcountries. There is also less differ-ence between urban areas indeveloped and developing countriesthan between rural areas, sincepeople who live in urban areashave higher incomes, are bettereducated and have better accessto health care. About 60-70 percentof physicians in Africa work inurban areas, where about 20 per-cent of the population lives. LatinAmerica is relatively well endowedwith physicians, but two-thirds ofthem serve the large cities whereonly a third of the population lives.This gap is much wider than canbe justified on the grounds thatspecialized referral services mustbe located in towns.

Some of the health problemsof developed countries, however,are magnified in developing ones.The need to achieve competitivecosts has led industries in somedeveloping countries to adopt lowerstandards of job safety than prevailin advanced countries, and accidentrates are high. Similarly, the numberof deaths per automobile is muchgreater than in advanced countries;for example, it is more than 100times higher in Nigeria than in theUnited States and 16 times higherper vehicle-mile. The joint use ofroads by pedestrians, animals,bicycles and motor vehicles is amajor reason for this.

Even though many of the diseasesand much of the death in develop-ing countries reflects an unhealthyenvironment, there are significantdifferences between rich and poor(see Table 5.6). The poor, whetherurban or rural, are more likelythan the rich to live where diseasesare endemic, and less likely to takepreventive measures or to seekprompt medical care even whenit is available. A poor family ismuch less able to tide itself overwhile a breadwinner is ill; even arelatively minor illness may plungeit from poverty into destitution.

I.Developing

Industrialized

0 20 40 60 80 100Percent

a. At current mortality rates.

Table 5.6 Differences in lifeexpectancy within countries

Illness

Nonfatal diseases are more commonand more serious in developingthan developed countries. But therelatively small proportion of peopleover the age of 65 in most developingcountries considerably reduces thesignificance of chronic, degenerativediseaseswhich affect about a thirdof the elderly in the United States,for example.

The most widespread diseasesin developing countries are thosetransmitted by human fecestheintestinal parasitic and infectiousdiseases, but also poliomyelitis,typhoid and cholera. These spreadeasily in areas without safe com-munity water supplies and goodhygiene practices. While they areleading causes of death in youngchildren, they are frequentlychronic and debilitating rather thancauses of acute illness or death.Their incidence is high. For example,the WHO estimated that in 1971about 650 million people hadascariasis (roundworms). A WorldBank study of construction workersat three sites in West Java, Indonesia,found 85 percent infected withhookworm.

Of the other diseases that usuallycause debilitation in adults ratherthan death, tuberculosis in particularremains extremely widespread.Most debilitating diseases trans-mitted by insects or other carriers

tend to be geographically moreconcentratedalthough in 1976it was estimated that 850 millionpeople lived in areas where malariapersisted despite efforts to controlit, and another 345 million in areaswith little or no control. Schisto-somiasis (bilharzia) is carried bysnails, which flourish in slow-moving water. It is severe in EastAsia, East Africa and in irrigatedareas of Latin America; an estimated180-250 million people are infected.

Trypanosomiasis (sleeping sick-ness) is found in a wide band inthe middle of Africa. It is generallyfatal if untreated in the early stages.Carried by the tsetse fly, it waslargely under control in the 1950s,but has revived because controlmeasures have slackened. Itconstitutes a serious risk to thelife and health of at least 35 millionpeople and has imposed great losseson animal herds. Chagas' disease,the Latin American form of trypa-nosomiasis, remains endemic inmany rural areas.

Onchocerciasis (river blindness),carried by the simulium fly thatbreeds in swift-running water, ishyperendemic in parts of WestAfrica and Central America. Insome areas it has led to the de-population of fertile river valleys.

Attempts have been made tocontrol these diseases by eliminatingdisease carriers through chemicaland environmental mechanisms,but with only limited and in someinstances temporary success. Insome cases effective drugs exist.Control requires a well-developedhealth service to monitor outbreaksof the disease and take remedialmeasures.

For children, illness obviouslydisrupts their attendance at schooland reduces their ability to con-centrate and learn. As for adults,research on the consequences oftheir diseases has been very limitedand has not produced consistentor generally applicable conclusions.

Some studies have shown thatmalaria control sharply reducedabsenteeismfrom about 35 percentto about 3 percent in one programin the Philippines in 1947. Anthro-pological research suggests thatsettlement on fertile lands hasoften been prevented by majordiseases. There have been surpris-ingly few detailed studies of theeffects of illness on productivityof individual workers; moreresearch is needed in this area.

It is also likely that disease dis-courages innovation, by makingpeople more reluctant to take risksor to commit themselves to activ-ities where precise timing is crucial.A study of Paraguayan farmerssuffering in varying degrees frommalaria found that severely affect-ed families obtained lower yields,cleared less land and avoided cul-tivating crops that required laborat specific times. In industry,capital may be substituted for laborwhere workers are frequentlyabsent because of endemic disease.

Difficulties of improving health

In its early stages, slowly decliningmortality in Europe largely reflectedimproved nutrition, housing andhygiene brought about by risingincomes. The spread of educationalso helped. The initial stages ofdeclining mortality in developingcountries have been based on anadditional factornew technologiesthat affect masses of people, suchas pesticides and vaccinations. Itis estimated that life expectancy indeveloping countries in 1970 wouldhave been eight years less thanwhat it was without the contribu-tion of these changes in publichealth technologies.

But some diseases, includingmost causes of diarrhea and manyrespiratory infections, cannot beprevented by currently availableimmunization or pesticides. Theirreduction comes through improve-ments in sanitary conditions and

55

Countryand region

Income(nationalaverage= 100)

Lifeexpectancy

(years)

Brazil, 1960-70Northeast region 54 47.9Southeast region 122 62.8

Tanzania, 1973Kigoma region 46 43.0Kilimanjaro region 215 55.0

Thailand, 1969-70North region 78 55.6Bangkok region 248 63.7

nutrition, and changes in individualhealth habits. These diseases havedeclined least in developing coun-tries and contribute most tomortality in those countries today.

There has been considerableconcern that developing countries,particularly in the high mortalityareas of Sub-Saharan Africa andSouth Asia, have not maintainedthe momentum of the 1950s inreducing disease. This is largelybecause countries have movedbeyond the "technological" phaseof improving health: the closerthey come to developed-countrylevels, the harder it is to progressat the same rate. It also reflectsthe fact that some communicablediseases have increased. Thenumber of cases of malaria, for

example, rose nearly threefoldbetween 1972 and 1976; otherdiseases have also spread, thoughnot so sharply.

These reversals have happenedpartly because authorities becameoverconfident and allowed controlprograms to run down. In addition,control became much more expen-sive in the early 1970s. Pesticideprices escalated and disease carriersdeveloped a tolerance for common,inexpensive pesticides (especiallyDDT). Economic development hassometimes made matters worse:small-scale irrigated agriculturehas expanded agricultural produc-tionbut also the habitat of snailsthat carry schistosomiasis.

Programs to control endemicdiseasesespecially malaria and

Oral rehydration

A simple innovation has revolutionizedthe treatment of a major killer in devel-oping countries. Diarrhea normally stopson its own accord after three to five days,but it occasionally causes a severe lossof body fluid; the resulting dehydrationis often fatal, particularly to young chil-dren. Replacing that fluid can preventmost deaths.

For more than a century, fluid has beenintravenously "dripped" into sufferersa method with obvious drawbacks incountries where there are few medicalfacilities. In the past 12 years it hasgradually been established that an oraldose has just the same effect. Even dur-ing diarrhea, the intestine continues toabsorb glucoseand glucose will carrywater and essential salts with it.

Oral rehydration had its most impres-sive initial success in 1971, in camps forrefugees from the Bangladesh war. Morethan 3,700 patients were treated in twomonths under extraordinarily difficultcircumstances, with a case fatality rateof 3.6 percent instead of the 30 percentbefore the treatment began. Oral rehydra-tion has since been used to prevent ortreat dehydration due both to choleraand to other diarrheas in many countriesof Asia, Africa and Latin America. Prop-erly delivered, it could save millions oflives a year.

The WHO currently recommends an

oral rehydration mixture consisting of:table salt (sodium chloride), 3.5 grams;bicarbonate of soda, 2.5 grams; potassiumchloride, 1.5 grams; and glucose, 20 grams.These ingredients are usually mixed andpackaged beforehand; the health worker(or a child's mother) simply dissolvesthe mixture in one liter of water. Pre-packaged mixes range in cost from $0.07to $0.10, and one to three packets mightbe needed while the diarrhea lasts.

There now is considerable interest inthe possibility that mothers could mix adose from the two ingredients that areavailable in most homessugar and tablesalt. But the recipe lacks potassium andbicarbonate (both of which are lostduring diarrhea), and using too much saltcould be dangerous for the child.

Home-mixing and the standard WHOformula are not, of course, mutuallyexclusive. One report (based on a fieldexperiment in Narangwal, India) recom-mended home-mixing for relatively mildcases of diarrhea, with a variant of theWHO formula used only for moresevere ones. This experiment placedprincipal responsibility for treatment inthe hands of auxiliary nurse-midwives(who live in the villages) and the mothersof affected children. While the incidenceof diarrhea changed little after the newtreatment was introduced, the casefatality rate declined by almost halffrom 2.7 per 1,000 to 1.5 per 1,000.

56

sleeping sicknessnow exist inmost of the affected areas. Theycan be operated effectively withoutpeople changing their behavior(though this is less true of schisto-somiasis, since people as well assnails play a role in its transmission).Pesticides can often be used moreefficiently.

There is also room for bettercoverage by immunization pro-grams, even in areas not otherwiseprovided with government healthservices. Sierra Leone, for example,employs recruitment teams; theyenlist the help of local leaders ingathering together everyone whoneeds to be immunized imme-diately before the vaccinatorsarrive in the village.

Apart from these efforts, majorprogress in family health behaviorand in the provision of healthservices is needed. Simple treatmentcan frequently be effective: forexample, the lives of children withacute diarrhea can often be savedby feeding them a solution ofwater, salt and sugar (see box).Education, especially of mothers,is important. Studies in 29 devel-oping countries have shown thatinfant and child mortality wereconsistently lower the bettereducated the mothers; each extrayear of schooling on average meantnine per 1,000 fewer infant andchild deaths. Cross-country studies(see box on page 38) confirm thatliteracy has a strong, favorableeffect on life expectancy. And asdiscussed below (see pages 66 and67) family planning services cancontribute directly to better healthof mothers and children.

Improved water supplies andwaste disposal are important inthe long run in reducing disease.But they must be accompanied bybetter hygienic practices if theyare to be fully effective. Wherefunds are short, water supplynetworks in urban areas usuallydeserve priority over sewers, which

are more expensive and less criticalto health. (Latrines, septic tanksand other lower-cost alternativesto conventional sewerage are lesslikely to contaminate water sup-plies if the water is centrally treatedand distributed under pressure inpipes.) But water supply systemsmust be maintainedsomethingthat is frequently neglected. AWorld Bank review of villagewater supplies found two coun-tries in which systems were fail-ing faster than they were beingconstructed.

Although heavy investment inwater supplies is often warrantedas a means of raising living stan-dards, it is unlikely to producequick or dramatic improvementsin healthand is expensive forlow-income countries. Even publicstandpipes and yard taps, whilemuch cheaper than conventionalhouse connections with internalplumbing, can cost more than $40per person (in 1978 prices). Incontrast, immunization against allcommon childhood diseases costsat most $5 per child.

Availability of health care

The amount spent on health carevaries widely throughout thedeveloping world, though it istypically very low. Governmenthealth budgets in low-income Africaand Asia are usually less than $5per person a year (and frequentlymuch less). Private outlays are oftenlargerin Bangladesh, for example,individuals spent an estimated $1.50each in 1976, or three times whatthe government was spending. Butthe combined total of $2 compareswith about $700 in the FederalRepublic of Germany. This gapwould remain huge even if allow-ance were made for differencesin prices. It is thus not surprisingthat in the mid-1970s in Bangla-desh there were 9,260 people perphysician, 5,600 per hospital bed,and 42,080 per nurse or midwife,

compared with 490 per physician,80 per hospital bed, and 260 pernurse in the Federal Republic ofGermany. (Some of the middle-income countries, though, havealmost as many physicians perperson as the developed countriesdo.)

For many necessary but simplemedical tasks, paramedical workersare likely to do a better job thanphysicians, who may be dissatis-fied with their work in rural areasand so turn to private practice.In many countries, however, thereare even fewer nurses than there aredoctors.

In many developing countries,people typically live in scattered,often small villages and cannottravel far. They are thereforeunwilling or unable to seek outmodern health facilities in urbanareas, except in extraordinaryemergencies. Moreover, whererural health facilities are available,they are usually far too small toemploy a physician full timeandcertainly too small to make efficientuse of equipment and auxiliarystaff. Although occasional visitsby traveling doctors and nursescan help, they are obviously unableto provide services at short notice.They may also not develop suffi-cient individual rapport withpatients.

Primary health care

The widespread provision of basicpreventive and curative medicalservices is essential. But in anattempt to tackle both the broadercauses of health problems andadministrative, political and otherimplementation problems (seeChapter 6), the WHO and UNICEFhave recently sponsored a conceptcalled "primary health care" thatgoes far beyond these services. Itis an integrated approach to healththat also spans food production,education, water and sanitation;in addition, it emphasizes self-

reliance and partnership betweencommunities and government.

The concept has achieved wide-spread intergovernmental support,especially from the 1978 Interna-tional Conference on Primary HealthCare. This has been no mean politicalachievement; but in most countriesthe rhetoric still must be translatedinto more money and reorganizedhealth systems.

A key element of primary healthcare, or of any health care systemthat attempts wide coverage atrelatively low cost, is the use ofcommunity health workers (CHWs)with limited training both to pro-vide front-line services and to referseriously ill patients or specialcases to larger dispensaries andhospitals (see box overleaf). Thepotential duties among whichtheir time must be allocated arematernal and child health care,midwifery, family planning, treat-ment of injuries and helping tomove seriously injured people toreferral facilities. In addition, theymay organize immunization andmass treatment programs, provideguidance on nutrition, family plan-ning and hygiene, and monitor epi-demics, water quality and sanitation.

Although several examples (in-cluding Chinasee box on page74) have shown that effective pri-mary health care is feasible evenfor low-income countries, it makesfairly heavy administrative de-mands. An effective coordinatedapproach is neededinvolvingcareful selection and training ofCHWs, thorough supervision,referral of serious cases to bettertrained and equipped people, andadequate (but controlled) availa-bility of drugs and other supplies.Without this, CHWs are likely tobecome demoralized, discreditedand inefficientand their recom-mendations for curative and pre-ventive care disregarded.

Moreover, the emphasis thatthis Report (and others) gives to

57

Lessons of experience

National experience with primary healthcare systems is still very limited. TheChinese barefoot doctors date from themid-1960s (see box on page 74). Duringthe 19705 countries a', diverse as Iran,Brazil, Sudan, India, Jamaica, Botswanaand Tanzania began large-scale systems.Their experience has shown which arethe key requirements of success.

Political support and finance, It isvital to secure the support of a substantialshare of the country's "health establish-ment"; without this, sound medicalsupervision and adequate finance will notbe possible, and primary health care willbe little more than an empty gesturetoward the poor. It is also important toensure that this type of medicine is notmislabeled as "second ate."

The Community Health Worker(CHW) should work cooperatively withthe community, if possible through suchrecognized organizations as the localcouncil or village development committee(as they do in Botswana and Sudan). This

- builds community support and increaseschances of improving family healthpractices; hours of service, use of drugsand materials, and patient satisfactioncan also be monitored. The communityorganization should have access to thesupervisor of the CHW.

At least part of the Cl-lW's salary shouldbe paid by government so that healthofficials can retain some on Ira I. But somelocal finance or voluntar',' efforts alsomake the CHW responsive to localconcernsand in turn can make thecommunity more aware of the servicesoffered, The government of India isproviding a stipend of 600 rupees a year($76) to "volunteer" health workers.Whether local pressures work in theinterests of the poor depends on the

degree to which the local political systemreflects these interests. China has suc-ceeded in making the community entirelyresponsible for compensating the CHW.But overreliance on local finance maymean that the poorest communities getthe worst attention,

Recruitment and training. The CHWshould be mature enough to enjoy therespect of the community. Early programsstressed formal education as a qualificationfor the CHW, and thus recruited youngpeople. Reviews of experience in Sudanclearly indicate that such people are noteasily accepted by communities. Ideallythe CHW should have children andpersonal experience with health crises,Programs now recruit highly motivated,older people even if younger applicantsare better educated, The CHW also shouldlive in the community; this has beenfound to reduce turnover as well as ensurefamiliarity with local culture. In somecountries, such as Iran and Yemen, it hasbeen necessary to train both a male anda female CHW because of objections totreatment by members of the opposite sex,

Community health workers must begiven enough training, equipment andsupplies to ensure that only one patientin four or five is referred to higher levels.High referral rates undermine the com-munity's confidence in the CHW andalso increase the probability of patientsbypassing him or her, This conclusionhas been confirmed by studies in Mexicoand Thailand. Moreover, several countriesfeel that CHWs should have the chanceto develop their careers, by competingfor entry into higher grades. Sudan, forexample, is planning to confine its "medicalassistant" training programs to CHWs.

Supervision and supplies. Frequentsupervision of the CHW is essential. Theisolated, modestly trained CHW is rarely

confident of his or her skills and oftenencounters difficulties that instructorsdid not anticipate. Experience in Tan-zania underlines the need for sound, con-tinuous supervision. Supervisors shouldboth provide in-service training and en-sure that performance meets minimumstandards. Iran, Sudan and Botswanahave found that it is better to overesti-mate the amount of supervision neededthan to risk undermining the confidenceand credibility of the CHW. Workersshould be visited regularly by staff fromneighboring dispensaries, health centersand hospitals as well as from the office ofthe regional medical officer. This compen-sates for frequent transport difficultiesor competing demands on the supervi-sor's time. In addition, it ensures thata broad range of issues (from clinicalcare to drug management) are consid-ered, and that visits from the outside areregarded as routine, not part of a crisis.

Providing facilities for telephone orradio contact between CHWs and super-visors has provided backup and helpedavoid unnecessary referrals in Honduras,for example. Physicians or highly trainedhealth personnel often give curative workpriority over supervision of CHWssonontechnical personnel should also playa part in the supervision and monitoringof CHWs.

A standard, simple set of drugs shouldbe provided to CHWs; if budget cuts arenecessary, they should not fall on medi-cines and supplies for the CHW (as hassometimes been the case). Standards arerequired for the use of drugs andsupplies; and the drugs provided toindividual CHWs should be monitoredto identify misuse or misappropriation.Kenya has developed a model programfor managing drug use, based upon care-fully devised treatment standards.

primary health care should notdetract from the importanceorunderstate the difficultyof strik-ing the right balance betweencommunity level activities and theback-up system that providesreferral services and supervision.Rural health centers, urban clinicsor district hospitals should dealwith various illnesses that arebeyond the scope of a CHW (thougheven they may not need a full-

58

time physician). These should comeunder the umbrella of a referralhospital with laboratory, x-rayfacilities, an operating theatre andbeds. (China, interestingly, hasgiven much more emphasis to thereferral system than is generallyrecognized.) Depending on popu-lation densities, transport, andincomes, the hospital could serve100,000 to 250,000 people andoversee the activities of three or

more clinics and about 50 CHWs.The balance struck between the

various levels of the health caresystem wifi depend on many factors,including financial and politicalsupport for the objectives of pri-mary health care, administrativecapabilities, the receptivity of thoseto be served, the extent of urbani-zation, and national income. Higher-income countries can afford toreduce the ratio of persons covered

per hospital and clinic, and to staffand equip them better. But evenin industrialized countries, thereis a strong trend toward moreemphasis on paramedical workersto improve the spread and effec-tiveness of basic health care andto help keep costs down.

In many countries it is alsodesirable to make use of, andprovide some training for, tradi-tional health practitioners, such as"ayurveds" in South Asia and thetraditional birth attendants foundin almost every country. This ispartly because they often have thetrust of their patients and becausepatients pay for their services(enabling government funds to bespread farther); but it is primarilybecause in many countries, includ-ing some of those where the world'spoor are concentrated, these prac-titioners provide near-universalcoverage of people who, realistically,will not be reached by effectivegovernment health programs forsome time to come. Training canhelp them to improve their treat-ment, dispense some modernmedicines and participate in healthor family planning education.

In addition, there is stifi an urgentneed for research to develop meas-ures to prevent or treat commondisabling diseasesfor example,malaria, schistosomiasis and themain causes of diarrhea in childrenthat are simple and cheap enoughto be applied within the frame-work of a primary health caresystem.

Nutrition

Systematic efforts at nationalnutrition planning in developingcountries go back barely a decade.During that brief time there hasbeen considerable progress inestablishing the extent and causesof malnutrition and what can bedone to reduce it.

Ten years ago, malnutrition was

often thought to reflect primarilya shortage of protein (and in somecases, vitamins or minerals). Mostnutrition programs concentratedon providing high-protein food tochildren, usually in schools. Theemphasis today is different. Thereis now a wide measure of agreementon several broad propositions.

Serious and extensive nutri-tional deficiencies occur in virtuallyall developing countries, thoughthey are worst in low-incomecountries. They are usually causedby undernourishmenta shortageof foodnot by an imbalancebetween calories and protein.There may often be shortages ofspecific micronutrients and ofprotein, especially among youngchildren. But given the typicalcomposition of the diets of thepoor, to the extent that calorierequirements (as estimated by theFAQ and the WHO) are met, it islikely that other nutritional needswill also be satisfied.

Malnutrition affects old andyoung, male and female, urbanand rural dwellers; particularlyprevalent among children underfive, it reduces their resistance todiseases and is a major cause oftheir death. In many societies, girlssuffer more than boys.

Malnutrition is largely a reflec-tion of poverty: people do not haveenough income for food. Giventhe slow income growth that islikely for the poorest people in theforeseeable future, large numberswill remain malnourished fordecades to come.

Poor nutritional practices andthe inequitable distribution of foodwithin families also are causes ofmalnutrition.

The most effective long-termpolicies are those that raise theincomes of the poor, and thosethat raise food production perperson. Other relevant policiesinclude food subsidies, nutritioneducation, adding minerals or

vitamins to salt and other processedfoods, and increasing emphasis onproducing foods typically consumedby the poor.

These points will be amplifiedin the following discussion.

Prevalence of malnutrition

Evidence of serious malnutritionin almost all developing countriescomes from three main sources:estimates of food consumption,anthropometric and clinical studies,and data on child mortality.

The estimates of food consump-tion by different income groupsnormally show that in all butthe richest developing countries,consumption by large sections ofthe population is well below whatis needed for a minimally satisfac-tory diet. Undernutrition is mostwidespread in Africa (where inmany countries food supplies havenot even kept up with populationgrowth) and in South Asia. It isalso common in Latin America andthe Middle East. Estimates of thetotal number of malnourished peopleare surrounded by controversy:there is dispute about what calorieand protein requirements are onaverage "adequate"; individualsmay have requirements very dif-ferent from the average; and withinhouseholds food often is notdistributed in proportion to indi-vidual needs. Nevertheless, allowinga wide margin for uncertainties,the evidence is strong enough toconclude that several hundredmfflion people are undemourished.

Anthropometric and clinicalstudies (based on measures ofheight, weight for height, armcircumference, skin-fold thickness,blood tests and so on) show, forexample, that children fromwealthier families, or from familiesthat have migrated to developedcountries, tend to grow substan-tially taller than do children ofthe poor.

The data on child mortality

59

reflect the combined effects ofsickness and malnutrition. Infec-tions can reduce appetite and foodintake in several different ways,including the action of intestinalparasites; and they can reduce theproportion of nutrients that thebody absorbs. Undernutrition inturn weakens the body's immuniz-ing mechanismsand so lowers itsdefenses against the initial infection,while making it more susceptibleto further infections. As previouslynoted, malnutrition is estimatedto be a contributory cause of athird or more of infant and childdeaths in developing countries (seepage 54).

Kinds of malnutrition

Most malnutrition reflects a short-age of calories, protein, or both.But some diets are inadequatebecause they lack specific nutrients.Anemia, resulting primarily fromblood loss and too little iron, isthe most prevalent example of this.A recent estimate is that at least500 million people are anemic. Theconsequent fatigue, the apparentlethargy and apathy, and the adverseeffects on productivity and schoolperformance can be so commonin poorer societies as to appearnormal. It is estimated that morethan half the victims of anemiaare adult women in developingcountries. Anemia due to iron andfolic acid deficiency is commonamong pregnant womenandharmful, because it can lead topremature birth and a much lowerchance of survival for the newbornchild. The more children a womanhas, the greater the probability ofsevere anemiaso adding to thecycle of poverty, high fertility andlow rates of child survival.

Goiter is another common dis-order (affecting perhaps 200 miffionpeople) caused by a micronutrientdeficiencyin this case, iodine.Available evidence suggests thatiodine deficiency can stunt physical

60

and mental development, and reduceenergy and motivation. In com-munities that have an exceptionallyhigh incidence of goiter, 4 percentor more of children may bedeaf-mutes or cretins.

Vitamin A deficiency is alsoextensiveaffecting, it has beensuggested, half the children inmany developing countries. In anextreme form it can lead to blind-ness. But in less serious formsit can still lead to poor eyesight,undermining educational per-formance and adult earning power.It can also affect growth, skincondition and the severity of othernutritionally related illnesses.

Victims of malnutrition

Young children suffer most fromundernourishment, followed bypregnant and nursing mothers. Inmany countries, there is considerableevidence that girls are less wellnourished than boys. This isespecially true of South Asia,where newborn girls have signifi-cantly smaller chances of survivingto age five; in a number of countries,induding some in the Middlle East,girls are weaned substantially earlierthan boys (see box on page 91).

Most childhood malnutritiondoes not result in early death. Butit means severe hardship beginningat birth, which may prevent childrenfrom ever escaping the povertyinto which they were born. Mal-nutrition stunts growth; in severecases it may retard mental devel-opment even after its physicaleffects have been shaken off. Severalstudies have shown that childrenwho have recovered from severeclinical malnutrition during theirpreschool years continue to dosignificantly worse in intelligenceand other tests than their unaffectedclassmates.

There is also some evidence,less conclusive, of the harmfuleffects of mild long-term malnu-trition; some studies in developing

countries have shown that better-nourished children (as measuredby height for age) do better inmental tests. It is not always pos-sible to isolate nutrition fromother factors affecting intelligence,but there is some evidence of itsindependent effects.

Malnutrition also affects earnings.In part, this reflects the consequencesof childhood malnutrition onmental development and educationalachievement; but there are alsolinks between nutrition and physicalproductivity. In the long run, adultscan only be as energetic as theirdiets will allowotherwise theywould gradually become emaciatedand ill. For example, farmers whoare badly malnourished put in fewerhours per hectare than those whoare better nourished. Research onthe relation between nutrition andproductivity has not been extensive,but a few studies have suggestedthat greater height or weight leadsto greater physical productivity.

In contrast to most other indicatorsof well-being, malnutrition in manycountries appears to be at least asserious in urban as in rural areas.Surveys in India, Brazil, Thailandand Indonesia have shown thatthe proportion of the populationwith very low calorie consumptionis substantially greater in urbanareas. This is partly because of thehigher cost of food in many urbanareas (although not in those withfood subsidies) and higher expen-ditures for such things as houserents and public transport.

But to some extent it is a signthat living and working in citiesis less physically demanding thanin rural areas, rather than an indi-cator of greater malnutrition.

In any event, because the poorare primarily rural, malnutritionremains primarily a rural problem.Rural populations are also morelikely to suffer seasonal variationsin food consumption; they are mostaffected in the wet season, when twin

peaks in farm work and widespreadinfection often coincide with the pe-dod when food is in shortest supply.

Causes of malnutrition

To what degree is malnutrition,especially among young childrenand pregnant and nursing mothers,caused by (a) inadequate familyincomes, (b) ignorance of goodnutritional practices and (c) theinequitable distribution of foodwithin families? There is someevidence that all three factors areimportant, but that low incomesare the central cause.

The famines in Ethiopia in1973-74 and Bangladesh in 1974were not caused by a fall in theaverage amount of food availableper person. Rather, droughts causedlocal declines in farm incomes, sothat people in affected areas couldnot afford to buy food from theunaffected areas.

At the global level, if incomewere distributed differently, presentoutput of grain alone could supplyevery man, woman and child withmore than 3,000 calories and 65

grams of protein per dayfar morethan the highest estimates ofrequirements. Eliminating malnu-trition would require redirectingonly about 2 percent of the world'sgrain output to the mouths thatneed it.

Major crop failures, which simul-taneously reduce rural incomes andnational food supplies, can haveeven more catastrophic effects onnutrition. While improved trans-port and international movementof food will reduce the impact onprices, events such as the twomonsoon failures in India in 1965and 1966 can have a terrible impacton the poor: supplies of basicfood grains fell 12 percent andprices rose sharply. Relative to theprices of manufactured goods,they were 37 percent higher in1967 than in 1963-65, In addition,the crop failures cut the incomes

Food and the poorAs people get higher incomes, they eatbetterand spend proportionately lesson food. The chart shows householdspending patterns in Indonesia, but itsessence applies to every developingcountry. The richest households spend ahigher proportion of their total budgeton housing, fuel, light and water thanthe poorest do on all nonfood items.

The composition of diets varies, too(a fact whose implications for policy areexplored on page 62). The poorest 30percent of people in Indonesia obtainabout 40 percent of their calories fromcassava and corn and 46 percent fromrice, while the richest 30 percent obtainonly about 14 percent of their caloriesfrom cassava and corn and 59 percentfrom rice.

Not only is food the main element inpoor people's budgets; but preparing ittakes up a lot of their time. Rice must bethreshed, winnowed and hand-milled toremove the husk and bran; wheat andmaize must be threshed, winnowed andground to produce flour; cassava mustbe skinned, boiled, pounded, strainedand dried to get rid of its deadly prussicacid; spices must be ground by hand; andso onall before any actual cooking isdone.

Composition of expenditure, byincome group, Indonesia, 1976

Poorest Richestdecile decile

Median100

so

5°

40

20

011000 2000 5000 10000 20000

Monthly total expenditore(rupiah per person)

Other

Durablegoods

Clothing

Housing,fuel, etc.

Other food

vegetables& fruits

Meat, fish,eggs & milkCereals

One study in a Java village found thaton average a woman works 11 hours aday. Roughly six hours are spent onincome-earning activities (wage work,handicrafts, producing food for sale).The other five hours are spent around thehome (collecting firewood, looking afterchildren, sweeping and so on)and pre-paring food, which takes three hoursa day.

not only of farmers, but also ofagricultural laborers, petty tradersand workers in food-processingindustries.

Poor people spend the bulk oftheir income on food. In India in1973-74 the poorest 20 percentwere devoting 33 percent of theirtotal spending to foodyet onaverage ate fewer than 1,500 cal-ories a day each. At these verylow levels, the consumption ofcalories (usually derived from thecheapest kind of food) changesalmost proportionately with changesin income. As incomes rise, a littlemargin enters the budget (see box).

A lack of money is frequentlycompounded by poor nutritionalpractices, Several common beliefsabout nutrition have harmfuleffects and must be attributed pri-marily to ignorance rather thanpoverty. For children, the weaning

period is particularly critical.While it is desirable to continuebreastfeeding for the first year oflife, milk should be supplementedby solid food by six months ofage; this is often delayed. It is alsolikely that the poor nutrition ofpregnant and nursing mothersmay at least partly reflect a lackof knowledge. Several studies havefound that better-educated parentshave better-nourished children:that this reflects more than thehigher incomes of educated parentsis suggested by the fact that themother's education is more impor-tant than the father's.

Educationespecially girls' edu-cationmay also help remedy oneof the most serious and intractablenutritional problems: the way foodis distributed within the family.A variety of evidence indicates thatin most developing countries adult

61

women receive a lower proportionof their food requirements thanadult men; girls are likewise gen-erally less well-fed than boys. Asbetween adults and children, thepicture is less clear: in many coun-tries children under five (and partic-ularly up to age three, when they areless able to take food themselves)do much worse than adults; insome countries, though, this is notthe case.

These sorts of discriminationsometimes reflect difficult choicesmade under severe economic duress,including a justifiable concern forthe breadwinner. But they alsoreflect ignorance of nutritionalpriorities and deep-rooted culturalbiases. (Concern for this problemappears to have been one of thereasons for the Chinese experimentwith communal feeding during theGreat Leap Forward in 1953-59.It encountered massive socialresistance and was abandoned.)

Nutrition policies and programs

The causes and consequences ofmalnutrition suggest variouscures. Boosting food production(especially of food that poor peopleeat and grow) and raising the in-comes of the poor are the twocentral requirements in mostcountries. They can be reinforcedby other effortsfood subsidiesof various kinds, fortifying food,and educating people to knowwhat a good diet is.

AGRICULTURAL PRODUCTION. In-creased food consumption by thepoor is in most countries unlikelyto be sustained unless productionis raised as well. For nutritionalpurposes, much can be achievedby producing more of what thepoor traditionally eatsuch asmillet and other coarse grains androot crops. These are, in general,the cheapest source of calories.They have other advantages, too.Some of them require less irriga-

62

tion and drainage than other crops;and, in the case of root crops, manycan be grown throughout the yearand some are drought-resistant.In addition, both root crops andcoarse grains tend to be producedby small farmers, who would bene-fit if encouraged to produce more.

Coarse grains can often begrown together with low-costvegetable sources of protein.Although cassava is very low inprotein, studies show that its priceis so low that most of the peoplewho meet most of their caloricneeds by eating a lot of it are ableto buy enough protein-rich foodto balance their diets. But therehas not been enough emphasis onthe production of cheap sources ofprotein, such as the cheaper varietiesof beans and lentils.

Despite long-standing neglectin research, extension services,access to credit and so on, in recentyears there has been greater aware-ness of the importance of foodseaten by the poor. The internationalagricultural research centers (inparticular those in India, Colombia,and Nigeria) have increasinglyextended their research to thesecrops and have given more atten-tion to nutritional issues.

Food marketing and storageprograms can also have a majornutritional impact by reducingregional, seasonal and annual vari-ations in food supplies and priceswhich contribute significantly tomalnutrition. Market stability canalso be helped by better transportand roads.

FOOD suBsIDIEs. Few low-incomecountries have come near to nutri-tional adequacy without someform of food subsidies. Sri Lanka'sration-and-subsidy program in 1970provided about 20 percent of thecalories and 15 percent of the in-comes of the poorest quintile ofthe population. Largely as a result,severe malnutrition was reduced

to a remarkably low level for sucha poor country. Because of this,and Sri Lanka's health and educa-tion services, life expectancy hasreached 69 years. When subsidizedfood rations were sharply reducedin 1974, largely because of a steepincrease in the price of importedfood, Sri Lanka's death rate rosenoticeably (even after allowancesfor other plausible influences); itdeclined again in 1976 and 1977,when food became more plentiful.Large-scale food subsidies are alsocommon in the Middle East andNorth Africa; they have played asignificant part in improving thenutrition of the poor.

But general food subsidies havea major drawbackthey are veryexpensive. They have cost as muchas 10-20 percent of governmentspending in some countries, includ-ing Egypt, South Korea (tempo-rarily in 1974-75) and Sri Lanka.Much of the cost is for imports,which use up scarce foreign ex-change or aid. And some of thisgoes to people who do not reallyneed to be subsidized.

Countries with strong adminis-tration can organize income testsnot perfectly, but well enoughto cut costs. Sri Lanka, for example,could have done more for thenutrition of the poor in 1974 if ithad concentrated the availablerations on them. In 1978 it intro-duced an income test to restrictsubsidies to the poorer half of thepopulation. But for many countriesthis would not be administrativelyor politically feasible.

Alternative ways of restrictingsubsidies to poor people includesubsidizing cheap foods that othergroups tend to neglect. Sorghum,a low-status food, was introducedinto ration shops in Bangladesh in1978and in some rural areas wasbought by nearly 70 percent oflow-income households, but only2 percent of high-income house-holds. Subsidized foods may be

confined to particular places. InColombia the nutrition programassisted by the World Bank pro-vides nutritionally enriched foodsto specific age groups living in thepoorest geographical areas, with-out a specific family income test.

The high cost of subsidies raisesanother difficultykeeping the pricereceived by farmers high enoughto encourage food production.Governments may attempt to pushdown domestic food prices to cutthe cost of subsidy programs; andfarm prices may decline if too muchfood is imported for the subsidyprogrammore, that is, than thenet increase in food consumption.But countries (and food-aid donors)can aniicipate and avoid adverseeffects on incentives. Well-designedsubsidies should be able to reducefood prices for consumers and also(since this increases the effectivedemand for food) to maintain pricesfor farmers. And proceeds fromfood aid sold through subsidyprograms can, for example, be useddirectly or indirectly to supportagricultural programs. Introducingsubsidies requires care, however,since the political cost of abandon-ing them is likely to be high.

SUPPLEMENTARY FEEDING PROGRAMS.

Some countries have gone furtherand have tried to target assistanceon the nutritionally most vulner-ableyoung children and pregnantand nursing mothers. In some casesfood supplements have been givenfor home consumption; in otherschildren have been fed directly.In both cases, however, benefitshave been shared with the wholefamilysince if children get foodoutside the home, parents tend togive them less from the family pot.

Studies of some preschool feed-ing programs in the mid-1970sshowed that schemes providingchildren directly with 300 caloriesa day gave them a net increase inconsumption of about 100 calories.

And only a small minority werein the most vulnerable group ofallunder two years old. Suchschemes tend to be relativelyexpensive: in a number of theseprojects, annual food costs aver-aged $10-17 per child, withadministrative costs adding afurther $3-7.

FOOD FORTIFICATION. Addingspecific micronutrients to food atthe processing stage is commonin both developed and develop-ing countries. But there are twogeneral difficulties. First, those whodo not need the supplement stillget it, so that the cost per personneeding assistance may be high,even if the cost per person receivingthe supplement is low. Second, thepoor may buy little processed food,and even that may be from small,scattered processorsso that for-tification is hard or uneconomicto arrange.

The best results have comefrom adding iodine to salt to pre-vent goiter; almost all high-incomecountries and some developingcountries have succeeded withthis. Annual costs are much lessthan one cent per person. Suchprograms are not yet universal(but may not be effective if peopleget much of their salt from non-commercial sources or very smallproducers).

Vitamin A has been added to avariety of foods (including tea,sugar, margarine, monosodiumglutamate and cereal products)in several developing countries.It is both effective and cheapfor example, three cents a persona year could provide 80 percent ofGuatemalans with 75 percent oftheir daily requirements. Muchmore could be done.

Since anemia is so widespread,adding iron to food has been triedseveral times. There have beentechnical difficulties, but these maynow have been overcome. But

anemia is not due solely to irondeficiencies, nor is it easily cured;effective programs that can beuniversally applied are still someway off.

It may sometimes be moreeffective to administer extranutrients directly (orally or byinjections). India and Bangladeshhave done this with Vitamin A (atsix-month intervals). But reachingthose at major risk every six monthsis usually impracticable. Manycountries have provided iron plusfolic acid pills for pregnant women;others have reduced goiter byinjecting people with iodized oil(a single injection provides protec-tion for three to five years).

NUTRITION EDUCATION. There havebeen few, if any, striking successes,but the potential effect of nutritioneducation is so vast that theattempt to increase knowledgeabout nutrition requires continuingstrong support. Clearly, educationmust be realistic: urging poorfamilies to buy milk might beharmful if they can afford it onlyby eating fewer calories.

Recent research on breastfeedinghas confirmed the value of breastmilk, not only for nutrition butalso for transferring to babiessome of their mothers' immunityagainst infections. In contrast,bottle feeding in unhygienic con-ditions tends to increase the riskof infection, and is expensive. Therole of advertising in promotinginfant milk formulas in develop-ing countries at the expense ofbreastfeeding has been questioned.In 1979, at a meeting sponsoredby the WHO and UNICEF, severalmajor multinational food firmsagreed to curtail direct advertisingof infant formulas in developingcountries. An international codeof marketing is now under consid-eration by the WHO.

Nutrition education will becheaper the more it can be made

63

part of education in general, com-bined with information on familyplanning and health, or tied tocommunity organizations or othercredible and influential communi-cations channels. In addition, severalcountries have experimented withrehabilitation centers for the severelymalnourished, which not only savethe child but show mothers how tofeed their children at home. Othershave experimented with massmedia; relatively simple messagesthat do not risk being misinterpretedseem to have made people more

Figure 5.3 Trends in birth and death rates, 1775-2050(births and deaths per 1,000 population)"

50 Per 1,000 population

aware of good practices, thoughthey have not always been putinto effect. The enormous amountof commercial advertising sug-gests that the value of mass mediain promoting social programs hasnowhere been adequately exploited.

PRIORITIEs AND PLANNING. As inother areas, difficult choices mustbe made in tackling malnutrition.There are simply not enough fi-nancial, political or administrativeresources to implement all thepolicies and programs outlinedabove. Some countries are attempt-

64

ing to assess relative priorities withthe help of national food and nutri-tion plans. These should ideallybe supported by successive samplesurveys of nutrition status, foodconsumption and production pat-terns by income group and regionwhich can show, for example,the likely nutritional impact ofalternative subsidy or productionprograms. Such plans, especiallyif effectively followed up, also offera way to focus the attention of,say, agricultural ministries on theimplications of nutritional priori-

ties for agricultural research, pric-ing, extension and other policies.

Fertility

In the past 10 years striking progresshas been made in understandingthe causes and consequences ofhigh birth rates, and in helpingto resolve two controversial andimportant issues.

The dispute between thosealleging that family planningprograms had little effect on birthrates and those alleging that familyplanning alone could reduce birth

rates has been greatly narrowed ifnot wholly settled. The evidenceoverwhelmingly suggests that bothsocial and economic conditions andfamily planning are important indetermining birth rates, and thatthey are mutually reinforcing.

Accumulating evidence dearlycontradicts the fear that healthprograms, by lowering death rates,will boost population growth inthe long term. Although fertilityseemed unresponsive to fallingdeath rates during the 1950s and1960s, it has since declined in manypoor countriespartly in responseto lower death ratesand popula-tion growth is slowing down.

Demogrciphic trends und projections

Figure 5.3 compares past and pro-jected trends in birth rates anddeath rates in developed and de-veloping countries. Two pointsneed to be emphasized. One is therapid population growth in thedeveloping world, after death ratesplummeted in the postwar years,and the continued rapid growthprojected for the rest of this cen-tury. The second is the drop inbirth rates, which began in the1960s in the developing world,and the resulting gradual slow-down in the population growthrate since thenfrom a peak ofabout 2.4 percent in 1965 to 2.2percent now.

Since 1965, birth rate declinesof at least 10 percent have occurredin the world's two most populouscountries, China and India, and ina number of other major devel-oping countriesIndonesia, thePhilippines, Thailand, Turkey andSouth Korea. Moreover, the recentrate of decline has been faster intoday's developing world than itwas in the 19th century in Europeand the United States. England andthe Netherlands took about 50years to reduce their birth ratesfrom 35 to 20 per thousandorabout one point every three years;

Brrth rate Death rateDeveloping countries

.

20 Deat(rate"U10

Birth rate

0

Developed countrtes

1750 1800 1850 1900 1950 2000 2050Rate of population increase = birth rate - death rate

Crude birth and death rates, The projected increases in death rates after about 1980 reflectthe rising proportion of older people in the population,

Include industrialized countries, the USSR and Eastern Europe,

Indonesia, Colombia and Chilehave recently cut about one pointevery year from their crude birthratesthough generally from higherinitial starting points.

Thus the comparison of currentbirth rates between the rich andpoor worlds should not obscurethe progress some developingcountries are now making in lower-ing fertility. Higher incomes, morewidespread education and thegrowing acceptability of familyplanning programs have begun toreduce birth rates in most middle-income countries in Latin Americaand East Asia, and in some countriesand regions of South and South-east Asia. With continued socio-economic progress the fertilitydecline is projected to spread tothe rest of South Asia and, withsome delay, to Africa, during the1980s and 1990s.

Even with these fertility declines,however, world population willcontinue to grow. By 2000, WorldBank projections (which arebroadly consistent with other pro-jections, such as those of the UnitedNations) indicate it will have risenfrom the current estimate of 4.4billion to about 6 billion; the pop-ulation of the developing coun-tries (including China) is projectedto increase from 3.3 to 4.9 billion.India will grow from 672 to 974million people; Brazil from 126 to201 million; Nigeria from 85 to153 million. These projections arebased on the assumption that cur-rent rates of social and economicprogress, including the spread offamily planning and health andeducation services, will continue;if they change, so will populationgrowth (see box).

It is instructive to consider theconsequences of an accelerationof fertility decline such as to causethe rate of population growth inparticular countries to fall to zero10 years earlier than currentlyprojected. The size of the resulting

Alternative population projectionsHow sensitive are population projectionsto changes in fertility and mortality rates?To illustrate, compare two projections forBrazil. The current World Bank projectionassumes that the total fertility rate (TFR)a measure of births per woman, stan-dardized for age distributionwill declinefrom 4.9 today to replacement level (aTFR of 2.2) by 2015. The Braziliangovernment has not officially recognizedrapid population growth to be a problem,but it does permit family planning forhealth purposesand the use of contra-ceptives (mainly privately bought) isincreasing.

What would happen if fertility reachedreplacement level a decade earlier, in2005? This is what the Bank projectionsassume for Colombia, a country withlower average incomes and roughly similarlevels of literacy and life expectancy, butwhich already has a government-supportedfamily planning program and significantlylower fertility (TFR = 3.7). For Brazil tomatch Colombia would require a sharpbut not unprecedented fertility decline.Birth rates would need to fall from 36per 1,000 people in 1978 to just below20 in 2000less than the fall of one pointa year achieved in the past two decadesby South Korea.

The figure illustrates the differences inthe size and composition of the Brazilianpopulation in 2020, under the alternativeassumptions of replacement fertility in2015 (Case I) or in 2005 (Case II). Twothings to notice:

Under either projection, the propor-tion of children in the population willdecline substantially between 1980 and2020. The current school-age (5-14) group

Alternative populationprojections, Brazil

Population (o:illior,)

238.4

p1980 2020 I 2020 II

of 32 million will increase by 10 millionunder Case I, only 4 million under Case IIcompared with an increase of 14 millionin the past 20 years, and 21 million inthe past 40. In 2020 under Case II, childrenunder 15 would constitute only 15 percentof the population, compared with 26 today.

Even in Case II, the working-agepopulation would more than double, from70 million today to 163 million in 2020.On the other hand, the number of newentrants to the labor force would beconsiderably smaller. In 2020 Brazil willneed to find about 4.5 million new jobsunder Case I, but only 3.3 million underCase II.

Reaching replacement fertility in 2005,not 2015, would make a big differencein the eventual size of Brazil's stationarypopulation (reached about 70 years later):it would be 287 million rather than 345million.

stationary populations would bereduced by, for example, 200 mil-lion in India, 50 million in Nigeriaand 36 million in Mexico.

Poverty nd high fertility

Poverty and high fertility aremutually reinforcing (see Figures5.4 and 5.5). As discussed in Chap-ter 4 (page 39), rapid populationgrowth is not always harmful. Re-duction of population growth isnot an end in itself; nor does it forevery country or for every point intime increase the potential growthof income per person. But in the

circumstances prevailing in mostof the developing countries, rapidpopulation growth impedes eco-nomic growth by reducing invest-ment per person in physical capitaland human skills. For individualfamilies the number of childrenaffects how much parents can in-vest in each one's health and edu-cationand thus in their futureearning power.

Quantitative analysis suggeststhat social and economic factors(such as incomes, literacy and lifeexpectancy) accounted for as muchas 60 percent of the variation in

65

300

250

200

150

100

50

0

Age

65-4-

- 0-14

266.4

15-64

126.3

Totalfertility

7.0Sub-Saharan Africa

Mid. East & N. AfricaSouth

- AsiaEast Asia

Latin America & Caribbean

Worldwide norm'

S. Europe

0 500 1,000 1,500 2,000 2,500 3,000

GNP per person (current dollars)

See technical notes for Table 16 of the WorldDevelopment Indicators.

Derived from cross-country equation relating totalfertility rate to GNP per person.

fertility changes among develop-ing countries from 1960 to 1977.The strength of family planningprograms explained an additional15 percent.

The strength of family planningprograms is influenced substan-tially by socioeconomic factors(which account for about three-quarters of its variation). This helpsexplain why family planning pro-grams in countries with high fer-tility, such as Pakistan, oftenappear weak even after years inoperation. This weakness is oftenwritten off as simply lack of gov-ernment effort. What the results

Figure 5.5 Influences on fertility

Government commitmentto poverty alleviationand fertility reduction

Reduction in poverty:Higher female literacyLonger life expectancyHigher incomes

Other cultural and social factors

66

suggest, however, is that programstend to flourish where their servicesare in demand. Nonetheless, gov-ernment efforts are vital.

Socioeconomic determinantsof fertility

Fertility is an area of human be-havior where individual tastes,religion, culture and social normsall play a major role. Yet evidencefrom large groups of people sug-gests that differences in fertilitycan be largely explained by differ-ences in their social and economicenvironment. What are the mech-anisms by which low education,poor living conditions, high deathrates and lack of health andfamily planning services lead tolarge families?

Consider the issue from thepoint of view of parents and poten-tial parents. They receive pleasurefrom their children but have tospend time and money bringingthem up. Children are also a formof investmentshort-term if theywork during childhood, and long-term if they support parents indisability or old age. Since chil-dren are a source of satisfaction,one might expect richer parentsto want more of them. Yet the op-posite is true, for several reasons.

The first is that the alternativeuses of timeearning money, de-veloping and using skills, leisure

Family planning

Smaller desiredfamily size

tHigher age at

marriage

Lower ertility

t /

become more attractive. This isparticularly true for women, whoare primarily responsible forbringing up children; as theiropportunities for education andemployment improve and theirhorizons expand, they often wanta smaller family. Second, withincreasing income, parents appar-ently prefer healthier and better-educated, but fewer children.They are more likely to wantmore education for their childrenwhen they believe that future jobopportunities will be governedless by class origin or familybackground than by education andassociated skills. Since this tendsto be a consequence of develop-ment, it can help to explain fallingfertility over time. Third, thechildren of the poor work at homeand outside the home at an earlyage: for richer parents, children'swork is not so vital to familywelfare.

If children help to support theirparents in old age, the (low) currentcosts of raising children are asmall price to pay. Where motherscommand only low wages, thedifferences between children's andmothers' earnings may be small;work lost by the mother duringa child's infancy may be easilyrecouped by the child later on.Finally, in poor countries muchof women's traditional workinagriculture, crafts and petty retail-ingcan be combined with lookingafter children.

The link between householdpoverty and high fertility is furtherreinforced by high rates of infantand child mortality; in poor familiesmany births and the high proba-bility of infant deaths go hand inhand. In the first place a motherwho stops breastfeeding becauseher baby dies is biologically morelikely to conceive another. Parentswhose children die often try toreplace them; and where highmortality is common, social norms

Figure 5.4 Income and fertility,1978

6.0

5.0

4.0

3.0

2,0

1.0

0

(which respond only gradually tochanges in mortality) tend to en-courage "insurance" against theexpected loss of children. On theother hand, high fertility contrib-utes to high infant and child mor-tality: many births, especially ifthey are close together, can weakenboth mother and children.

FAMILY PLANNING. The link be-tween household poverty and highrates of childbearing is furthercemented by the fact that the poorstill have very limited access tomodern and simple means ofcontraception. The contraceptivesavailable are often expensive, par-ticularly in relation to the incomesof the poorand especially if theymust be bought from privatedoctors. For a poor family, limitingthe number of children may there-fore mean sexual abstinence,illegal abortion, infanticideor,at best, ineffective and difficulttraditional contraception. In somecircumstances, the psychologicalor financial costs of avoidingpregnancy may exceed the costsof having another child.

Family planning programs thatare well designed and implementedmay legitimize what relatives,friends, the community, the clanor village might otherwise havefrowned upon. These social normsare often influential. Recent evi-dence indicates that decliningfertility in 19th century Europewas not associated with economicfactors in any consistent way. Butit did follow a similar pattern acrossregions defined by a commonlanguage or cultureimplying thatthe idea of limiting family sizecan affect fertility independentlyof specific economic change.

The same tendency can be seentoday: even taking income andeducation differences into account,there are national and regionaldifferences in fertility (Figure 5.4)that appear largely the product of

cultural or religious differences.But culture never seems to havebeen an impenetrable barrier tofertility change. Once a high enoughlevel of development has beenreached, fertility has fallen withoutexception. Where there was a strongreligious or cultural resistance tocontraception, as in Ireland, fertilityfell through delays in the age atmarriage and an increase in life-long celibacy, rather than throughfamily planning.

AGE AT MARRIAGE. Recent de-clines in birth rates partly reflectrising age of marriage amongwomen. This has lowered the rateof population growth by lengtheningthe interval between generations,by shortening the period duringwhich women are likely to havebabies, and perhaps by givingwomen other interests beyondfamily and childbearing to takewith them into married life.

Like marital fertility, age atmarriage is strongly affected bysocial and economic conditions,including women's education andemployment opportunities. Theaverage age at marriage (correctedfor the proportion of women whonever marry) is 22 in the middle-income countries of Latin Americaand in Malaysia, Singapore andSouth Korea; but it is less than20 (sometimes much less) in manySub-Saharan African countriesand in Nepal, India, Pakistan andBangladesh.

Later marriage as a mechanismof fertility reduction has been mostimportant in Asia. In the 1960sin South Korea and PeninsularMalaysia, changes in the proportionof women married accounted forabout half as much of the declinein the crude birth rate as did changesin marital fertilityand were moreimportant than marital fertilitydeclines in Sri Lanka and thePhilippines. China has placed greatstress on delaying marriage in its

program to reduce populationgrowth.

In Latin America, later marriagehas been a less important ingredientof declining fertility.This has beenpartly because average age at mar-riage was already high comparedwith Asia, partly because muchof the fertility decline in suchcountries as Chile, Colombia andCosta Rica has been among olderwomen, and partly because child-bearing outside wedlock is morecommon. Fertility is generallyhigh and age at marriage lowthroughout Africa and the MiddleEast.

Population policy and familyplanning programs

Lower fertility is not an end initself, but one among several waysof improving human welfare. Norare the benefits of family planningsimply economic. Relatively fewcouples, even among the poor, wantas many children as their naturalfertility would allowwitness thehospitalization rates due to self-induced abortion in Latin America,and scattered evidence that someparents do not always do all theymight to avoid infant deaths,particularly of daughters. Poorwomen are particularly helped byfamily planning services; so arechildren, who can benefit from asmaller family.

The case for the public provisionof family planning services, andensuring that the poor have accessto them, is gradually becoming lesscontroversial. Some 35 developingcountries, with 78 percent of thedeveloping world's people, havean official policy to reduce popula-tion growth. An additional 14percent of the developing world'spopulation lives in countries wherefamily planning is supported forreasons of health and welfareincluding the health benefits thatcome from fewer children.

Some countries have had striking

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successes. In Thailand contraceptiveuse increased from 11 to 35 percentof rural married women between1968 and 1975, and from 33 to 49percent of urban married women.In Indonesia the governmentexpanded its service in 1974 froma clinic-based approach, to onebased in villages. It currently has3,500 clinics, 25,000 village depotsand 40,000 village family planninggroups. The proportion of marriedwomen using modem contraceptivesincreased from 7.4 percent in 1974to 18 percent in 1977; it was 0.2percent in 1970.

Nor need a population policybe confined to the support offamily planning programs. A fewcountriesmost notably Singaporehave used tax and housing policiesto discourage large families. Directpayments for sterilization have beenan important part of the Indianprogram. China, which for severalyears has emphasized that latermarriage and small families arepatriotic, recently announcedbonuses and preferences for one-child families, and tax and housingpenalties for families with morethan two children. Raising thelegal minimum age at marriage(the median among all countriesis still only 15) might also help,although efforts to date have notbeen particularly successful (withthe possible exception of China).

IMPROVING ACCESS TO coNTRAcEP-

TION. Before 1960 family planningservices were provided largely byvoluntary associations. Mostprograms were small and offeredservices through health centersand private clinics, promotingsimple barrier methods (foam,condoms and diaphragms) andrhythm. In the 1960s oral contra-ceptives and the intrauterinedevice (IUD) became availableand sterilization and legal inducedabortions became more common.These required clinical support

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and well-trained practitioners,making programs heavily depend-ent on the health system.

This has caused difficulties formany countries where medicalfacilities and personnel are toolimited to provide adequate familyplanning coverage. But if theyoperate within the framework ofthe health service, middle-levelhealth staff and people speciallytrained in family planning haveproved effective substitutes formedical specialists. In Thailandand South Korea the use of para-medical personnel for screeningpatients and supplying contracep-tive pills led to increased acceptanceof these pills. Family planning aidesin Pakistan and Bangladesh havelearned to insert IUDs, and in Indiato carry out menstrual regulation(inducing abortion of possible butunconfirmed pregnancies at anearly stage). On a trial basis, theyhave been trained to performsterilization.

Separate family planning serviceshave not been so successful. Thead hoc systems (in Pakistan, forexample) have at times involvedambitious programs of regularhome visits to persuade peopleto plan their families, and to supplycontraceptives. But without a sat-isfactory health network, it maybe difficult to supervise the staffand provide more specializedadvice or assistance to the fewpeople who develop complications.

A promising alternative approachis to use other administrative net-works. From time to time, Indiahas had government personnel,such as teachers and tax collectors,recruiting people for sterilizationalthough this became unpopularthrough abuse. The successfulfamily planning program in Indo-nesia (see box on page 80) hastaken advantage of strong com-munity organizations and madeextensive use of village workers,with clinics to which people can

be referred for further help.Several countries have greatly

increased the number of placeswhere pills and condoms can bebought, often at subsidized rates.But simple and safe barrier methods(condoms, diaphragms and spermi-cides) are still neglected in manydeveloping countries despite theirrenewed popularity in developedcountries. Their use could sensiblybe encouraged; research into waysof making them more practical indeveloping country settings isneeded (see box).

FUTURE PRIORITIES. Progress inreducing fertility will partly dependon increasing the demand for con-traceptionprimarily through socialand economic development thatsuccessfully reaches the poor, butalso through the growing under-standing that fertility is a matterof individual choice. It will alsodepend on providing effectivefamily planning services. Both willbe facilitated if contraceptives canbe made more convenient and lessprone to complications that needmedical attention. And the impor-tance of political commitment toa population policy should not beunderestimated. Countries with adual concern for social and economicadvance and for family planningwill be able to cut fertility ratessubstantially in the rest of thiscentury, and beyond.

The seamless web

Chapter 4 stressed that education,health, nutrition and fertility sig-nificantly affect the incomes of thepoor. This chapter has consideredseparately each of these main areasof human development, with spe-cial emphasis on the causes ofchange and the policies that canbring it about. But it is worth reit-erating that the different elementsof human development are keydeterminants of each other.

Contraceptive technology

Of the people who use some form ofbirth control (about two-thirds of themin developed and one-third in developingnations), roughly one-third are sterilized,about 20 percent use the pill, 15 percentthe intrauterine device (IUD) and 13percent the condom. Most of the remain-ing 19 percent use rhythm, abstinence,the diaphragm, contraceptive injections(which last one to three months), varioustypes of spermicide and such traditionalmethods as withdrawal, postcoital douch-ing and deliberate reliance on the anti-fertility action of breastfeeding. Thoughthere is evidence of widespread illegaland self-induced abortion, safe and legalabortion is available in only a few countries,and publicly provided in even fewer.

The amounts spent on research inreproductive sciences and contraceptionhave been smallless than 2 percent oftotal government spending on medical

research in the mid-1970s. And publicspending on applied contraceptiveresearch has fallen as much as 50 percentsince then. The (smaller) amount spentby pharmaceutical firms has probablyalso fallen, apparently because newmethods are not expected to be profit-able. Unless more is spent, new tech-nologiesvaccines, menses-inducingdrugs, pharmacologic methods for men,and much improved barrier contraceptivesthough technically within reach, areunlikely to be developed or tested formany years.

Applied contraceptive research is stilllargely directed at female contraceptives(about nine times more was spent onfemale than on male methods in 1978),partly because basic research on thefemale reproductive system has been moresuccessful. It is also geared almost exclu-sively to the search for new hormonal,drug-based and surgical procedures:more than $10 million was spent on these

in both 1977 and 1978. In contrast, spendingon the simpler barrier methods was lessthan $500,000despite their potential forimprovement (a biodegradable condomor a standardized plastic-based diaphragm,for example).

Present barrier methods are generallyviewed as too ineffective and inconvenientfor widespread use in developing countrieswhere sanitary conditions are poor,privacy is less, husband-wife communi-cations are more formal and abortionas a backup is more difficult to obtain.In the United States, however, use of thepill is falling, that of the diaphragmincreasing; consumer concern over theside-effects of both the pill and IUD hasincreased. Whether such concerns arewell-foundedand on this there is noconsensusthey are bound to spread todeveloping countries. In the 1980s theefforts to extend services to more peoplemay have to be complemented by a widerchoice of methods.

Public health careWater supply, sanitationand housing

Public education

Figure 5.6 Policy and poverty

Land ownership and tenureTechnology and researchDomestic savingExternal capitalInvestment allocationAgricultureExternal tradeTaxation and transfers

Food productionSubsidies/rationsFood fortification

Family planningIncentives

The seamless web of interrela-tions constitutes the core of Figure5.6; feeding into this core are thevarious areas in which policy affectspoverty. The diagram is illustrative,and the policies shown are not theonly determinants of poverty orof human development. As hasbeen stressed, climate, culture,religion and natural resources allshape the environment in whichdevelopment takes place andinfluence the choice of policies.So do political realities, adminis-trative constraints and the worldeconomy.

Some of the links are simplycommon sense: it is not surprisingthat the incomes of the poorsignificantly affect their health,education, nutrition and fertility.Poor people cannot afford decentfood and health care; they are morelikely to need their children'smeager earnings (or help in thehousehold and fields) so that thechildren cannot go to school. Andthey feel more need to have largefamilies to support them during

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old age and disability. Averagenational income is obviously alsosignificant, especially since it af-feds the tax base and hence thegovernment's ability to financehuman development programs.

Some influences are less familiar.The effects of primary educationhave been stressed above in numer-ous contexts. For example, parentswith a primary education are morelikely to learn about (and be willingto try) improved health, hygieneand nutrition practices, thusreducing the chances that theirchildren will become ill or mal-nourished. Educated people aremore likely to have lower fertility:they more readily see the dis-advantages of having too manychildren to feed and educate; theyhave more alternative sources ofinterest and satisfaction thatcompete with children for timeand money; they are generally morewilling to accept new ideas, suchas the use of modern contracep-tives, and to seek family planningadvice. Because of the mother'spreeminent role in bearing andraising children, it is not surprisingthat her level of education is more

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important than the father's.Health and nutrition both affect

whether children can attend schoolregularly enough to finish the pri-mary years, and whether they havethe mental and physical energyto learn. Malnutrition and diseasehave been found to be closelyconnected, each increasing thelikelihood and severity of theotherwith death often the endresult. Better health plays a keyrole in the demographic transitionto lower fertility: when the oddsare greater that children will surviveto support their parents in old ageor disability, parents tend to havefewer children. Although it ispossible (though not firmly estab-lished) that better nutrition mayincrease natural fecundity, its effectson the health, education and incomesof the poor all contribute indirectlyto reduced fertility.

Lower fertility itself affects theother aspects of poverty. The spreadand quality of education increasesbecause both the state and parentscan afford to spend more on eachchild when there are fewer of them.Large families have higher infantand child death rates and a higher

incidence of malnutritionthere issimply less food, money and timefor each child.

It is also important to take along view. Although a certainamount can be done with crashprograms such as vaccinationcampaigns and adult literacyprograms, sustained human devel-opment is usually a slow process.In general, a country's level ofhealth, education, nutrition orfertility at any given time largelyreflects its level 10, 20 or even 50years earlier. At any given level offamily income, children are morelikely to go to primary school iftheir parents have also done so;and because the home environmentencourages learning, particularlyin the preschool years, they arelikely to do better in school as well.

Human development is thustransmitted from generation togeneration in a virtuous circle; butequally, there is a vicious circlethat sentences the children ofdeprived parents to deprivationthemselves. Breaking out of the vi-cious circle into the virtuous one isthe essence of human development.

6 Implementing human development programs:some practical lessons

This chapter concentrates on fourkey questions that invariably affectthe way human development pro-grams are organized, and howeffective they are.

Political support. This has beencritical to the considerable successof human development programsin reaching the poor. Its absencealso helps to explain some of thefailures.

Finance. Money alone will notproduce human development. Buta shortage of funds is a com-mon, often binding constraint. Somethods that reduce unit costsor raise new revenues have aconsiderable role to play inexpanding services.

Administration. For manyprograms, administrative andinstitutional capacities may beeven scarcer than finance. Yetproject experience shows that theirimportance is frequently overlooked.

Demand. The way familiesand individuals respond to servicesis crucial to improving health,hygiene and nutrition; to whetherchildren from poor families go toschool or have to work instead;and to reducing fertility.

These four factors like education,health, nutrition and fertilityareclosely interlinked. For instance,financial and administrative con-straints can be eased by politicalsupport, which in turn will bestronger if programs can be madeless costly or administered morereadily, or if there is a heavy demand

for them. The links, though, arenot all complementary: for example,paramedical workers have lowersalaries than doctors, but they needmore supervision.

Human developmentneeds political support

Political support for human devel-opment cannot be taken for granted.The poor frequently are politicallyweak. They are often too sick,uneducated, geographically dis-persed and busy to be politicallyactive. Influential elites, particularlylarge landowners, may opposehuman development programs ifthey feel that their power and statusmight be undermined. They mightfeel, for example, that educatedchildren are less likely to settle forworking in serf-like conditions onhaciendas or plantations.

Even if there is no direct oppo-sition, the extent and form of humandevelopment programs will generallybe influenced by keen politicalcompetition for limited tax revenues.Because policymakers generallylive in urban areas, as do the mostpolitically active of the people whobenefit from public services, theseprograms tend to suffer from urbanbias (though reductions in urbansocial expenditures do not neces-sarily lead to increases in ruralexpenditures). But the health andeducation facilities available evento urban elites in poor countriesare generally inferior to those

available to the middle class in richcountries. A major political chal-lenge of the 1980s will be to adaptand extend programs to the poor,particularly those in rural areas.

Despite the difficulties, it hasusually been easier to obtain politicalsupport for health and educationprograms that benefit the poorwitness the large increases in schoolenrollment and life expectancythan for policies of, say, land ortax reform. Why? Largely because,unlike land reform or increasedtaxation, more knowledge, healthand vitality for the poor are notobtained by reducing them forsomeone else. Of course, suchprograms must be financed. Therich may have to pay more in taxesthan they get in direct benefits.But they are often prepared tosupport human development, inpart because it has a legitimacythat transcends culture, religion,ideology and class. This is particu-larly true if poor children areinvolved. The idea that all childrenshould have a fair startwithoutthe handicaps of disease, illiteracyand malnutritionis widespread.

In some circumstances, more-over, everyone gains. Those whoare not poor will benefit if endemicdiseases are eradicatedpreventionusually being cheaper than cure.Malaria control is an obviousexample: the main beneficiariesare the rural poor, who are mostlikely to be infected. But mosquitoesthat bite the infected poor may

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