UNICEF: The State of the World's Children 1981-82

8/8/2019 UNICEF: The State of the World's Children 1981-82

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THE STATEOF THEWORLD'SCHILDREN1981-82

James:P. GrantExecutiveDirectoroftheUnitedNations Children'sFund(UNICEF)


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CONTENTS

Children in dark times PageA year of silentemergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ISocial goals and the slowing of progress . . . . . . . . . . . . . . . . 2The 'realism' of meeting children's needs 2The largest generation . . . . . . . . . . . . . . . . . . . . 4Wanted: more benefits per dollar for childrenRecruiting an army of para-professionals 5Participation: the foundations of development 6Synergisms: making one plus one equal three 7Linking what science knows to what children need . . . . . . . .. 7Beyond the theory 8Investing in children - social justice and economicsenseBasic needs and a new economics 9Political will and changing priorities , .. . . . . . . . . .. .. .. 10Tec hnology and social organization 10Learning from development's disappointments 11UNICEF: applying the lessons 12


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Yet a more recent United Nations study has nowconcl uded that ' the world economy is experiencinggreater instability and a more severe disruption ofsteady growth than at any time since the end of theSecond World War . . . unless specific steps are taken,the consequence of this adverse external environmentwill be to increase the numbers of the absolute poor toone billion before the end of the Third DevelopmentDecade' .It was a conclusion accepted by the heads of allUnited Na tions agencies, including the World Bankitself. And, in all probability, it means that, in manycountries, more children will die next year than this,Social goals and the slowing down ofprogress

Last year, in this report, UNICEF asserted that bythe year 2000 the number of infant deaths in lowincome countries could be reduced to 50 per 1,000 orless, that average life expectancy cou ld be raied to 60years or more, and that every child should have at leastthe four years ofprimary education necessary toacquireliteracy. The reportDoted that although idealistic in thecontext of past experience, these goals are realistic inthe sense tha t the principal obstacle standing in theway of their realization is the absence of the will andcommitment to achi eve them.In D ecember 1980, those targe ts (advocated bymany organizations in recent years) were incorporatedinto the International Development Strategy (IDS) forthe 1980s and adopted by theGeneral Assemblyof theUnited Nations, I An important new feature of thestrategy', said Mr . Niaz-Naik who chaired the committee which prepared the IDS, l is that it conceives ofdevelopment as an integral process, and the objectivesof social and human development have been accordeda new emphasis,'But with the decadejust beginning, itis already clearthat its principal economic target - a seven per cent ayear avera ge rise in the GOP of the devel oping nations- is unlikely to be met Unless special measures aretaken, therefore, the vision of its social goals is alreadyclouding over,

To reach sucb goals, progress towards them wouldinfact have to be two or three times as fast over the next20 years as it has been over the last 20. But in manynati ons today, the rate of development as measured byall three of the chosen indicators is already slowingdown,The Third World's infant mortality rate - thatsensitive indicator of the well-being of mothers andchildren - fen by a steady four or five points a year inthe I960s. For the past five years, it has barelyflickered, Average lifeexpectancy, which increased byseven or eight months a year in !he 1960s and early1970 s, is now increasing by only two or three months ayear. School enrolment rates, which again rose by aregular four or fiveper centa year up to the mid-1970s,now seems to have reached a plateau,

With the developingworld ' s infantmortality still tentimes higher than in the industriali zed world, with itslife expectancy still 15 years less, and with a third of its6-11 year olds still out of school, this deceleration ofprogress cannot be explained by the approach of anynatural limits , Rather it is a sign that development itselfis in some nations becalmed and in othe rs actuallydrifting backwards.In short, the optimism of the 1960s which gaveground to the realism of the 1970s has now recededeven further tomake room for the doubt and pessimismwhich seems to be se ttl ing into the 1980s. It is a

process of disillusionment both aggravated and symbolised by the decline in the share of the rich world'swealth which has been invested in aid In 1965, whenthe United Nations first called upon the donor countries to increase the level of their aid to 0,7 per cent oftheir GNPs, the actual leve l stood at 0.49 per cent,Today, despite the efforts of a handfu l of nations whohave met that target, the average level rests at 0 .37per centNot in a generation have expectations of worlddevelopment, and hopes for an end to life - denyingmass pove rty. been at such a low ebb,In such a context, to advocate the rapid accelerationof deve lopment progress for the world's poorest billionpeople in order to significantly improve the lives oftheir children by the end of this century is to invite thecha rge of naivety,It is a ' naivety' which UNICEF intends to pursuewith the utmost vigour. Workingwith communities andfamilies to provide for the health and education of theirchildren is not only a matter of justice, It is also aproductive investment in the world's economic andsocial future,The ' Rea lism ' ofmeeting children's needsThe realism or naivety of any goal is almost always

as much a question of priorities as of possibilities. Andit is not the possibility of achieving primaryhealth careand primary education for the great majority ofchildren which is in question. It is its priority,Such goals could be achie ved, for example, for lessthan the industrialized world spends on alcoholicdrinks each year, Similarly, the broader goals ofmeeting the basic human need s of the overwhelmingmajority ofmen, women and children on earth could berealized by devoting as much each year to the task ofachieving them as is now devoted every six weeks tothe task of maintaining and increasing the world'smilitary capacity,However uncomfortable such comparisons may be,they are necessary to put into perspective the accusation that the goal of making significant improvementsin the lives of the world' s children by the end of thiscentury is 'naive', and to put in its place a deci sionabout priorities.In dark times, chi ldren need priority. And whilethere will alway s be emotion behind that statement, itis also an appeal to reason,More specifically, it is an appeal to two reasons one of which is timeless and one ofwhich is particularto this, the last quarter of the twentieth century,

Ninety per cent ofthe growth ofthe human brain and50 per cent of the growth of the human body occurs inthe first five years of the human life, The correspondingsusceptibility of those years should alone argue thatpriority be given - in family affairs and inworld affairs- to the needs of the young.In the acquisition of their needs, and in the defenceof their rights, children thems elves are relati velypowerless. They have neither physical strength, noreconomic sanction. They have no unions, and novotes ,Usually it is the parents who are empowered toprotect and provide , But ifparents are deprived ofthatpower, then the responsibility falls to the communityofwhich the child is partIn the very earliest human societies, as RichardLeakey has shown, average life expectancy was probably little more than 20 years and many child renweredeprived of both their parents before they were of an


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Three decades of progress: income. health. aducation. 1950-80

"..

IncomeGNP .Pt""" (JMOfklffml "SO 'NO "..IndUJtiUl countnt s 4,130 5,580 10,660 "50Mldd1r-uw:ornt- countnfs MO 820 ' ,580Low ancomerountnn 170 180 250 ."

""WN!f' .,.11" " I l'\Rl'tll(pmnlJ .".. ... ,......Industnl l countries 3.1 33Midd le-income countries 2.5 3.3Low-Income:countries 0.' 17

'''',...l lMl,nlrbJ (O U al106

I:J cf1l14Jf'-IMOlllt AVlrr"S t ,,"" ,u l 111>...1"' e CtllO,'UrIe1 ' f'l'fI.... , M lool,... - ,I l" d"otrl. l 11\(0_ 4~ f i f l , - ,.1 , .tLo_ l ncoltW l _ ,M .,.". _ 2(Qunl, l,s TrryU - I--Health l Ilt n pu u n()' M borth t . ' $ ,.'Ulloon pflJfllt11lhII:ri.l1l.:ft r.rp t. "O/ . , M il hinN} t lNam. t,- ,..''''' ' NO ' ,,,...,, ,nInduSlri.l.lcountnn 67 70 " Mlclclw.l_Mlddleincome ee.lnltiH"SOeccnmes


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provide tor children has been eroded or washed awayby unemployment or landlessness, by poverty or bylack of knowledge, by sickness or disability, byoppression orbydemoralization And inexercising itsresponsibility to those children, the task facing bothnational and international communities isto find waysof restoring that power to their parents.The largest generation

This timeless concern is today sharpened to aparticular edge by specific changes in the growth andstructure of world population.After a rapid increase in the rate of populationgrowth - caused by relatively sudden successes incontrolling certain diseases, epidemics and faminineswhich meant that more infants survived to have childrenoftheir own- fertility rates have now begun to fall inalmost every region of the wor ld The beginning ofthis decline is as unprecedented as was the surgingincrease which preceded it Taken together, bothforces now have 8 special bearing on the state of theworld's children.One effect is that 40 per cent of the developingworld's people are under the age of 15 and about toenter their child-bearing years. As birth rates fall, thenumbers of children as a proportion of the totalpopulation will also fall. But in our time, the ThirdWorld 's ratio of younger to older - of dependants toproviders - is at its height In Germany or the USSR,forexample, there arenowtwopeople of working agefor everyone whois too young ortoo old towork. InBangladesh Mexicoor Nigeria, the ratio isoneto one.The result is a temporary butpowerful extra strainon the Third World's capacity to provide for itschildren. In education, for example, those of primaryschool age now amount to 25 per cent of the population. In the industrialized world, the correspondingfigure is only 15 per centThe decline in fertility which is just beginning tobecome visible will in time lower that proportion. Butmeanwhile the capacity of the ThirdWorld toprovideessential services for the young is stretched to the limit- and beyond - by quantitative pressures on lowincome countries which leave little room for thequalitative improvements which are required toimprove the well-being of the world's children.Whenthese internal pressures coincide, as is nowhappening. with external economicpressures resultingfrom world-wide recession, then the welfare of thelargest generation of children in history is furthersqueezed.As nutrition, health, educationand the normalciesofchildhood are usually preconditions of successfulparenthood, it is vital to both this generation and thenext that the children of today be protected against thepresent economicweather.The welfare of children- and future parents - isnotthe only issue at stake. For the question of whether ornot improvements in the lives ofthe young are broughtabout in the 1980s is also crucial to the slowing downof population growth itself.Acceptanceoffamily planning and a decline in birthrates is closely connected with such changes as theimprovement of health care, the decline of infantmortality, and the spread of education (especially forgirls). A setback in progress towards these social goalsis, therefore, likely to also be a setback in the trendtowards lower population growth - so increasing thenumbers of children in future generations atthe sametimeasdecreasing their parents capacitytoprovide forthem.

Conversely, the stepping-up of national and internalional efforts to meet such needs would have theopposite effects of both improving life for the childrenof today, investing in their capacity as the parents oftomorrow, and creating theconditions necessary forafurther slow-down in population growth itself. Extrapolating the experience of thosedeveloping countrieswhich have lowered death rates forexample, suggeststhat the very same improvements in human welfarewhich would be required to meet the InternationalDevelopment Strategy's year 2000 target of reducinginfant mortality to 50 per 1000 births or less wouldalso result in 12 to 20 million fewer births each year.History demonstrates that when overall death ratesmake that first precipitous fall from around 40 per1000 as a result of eliminating mass famines andepidemics, then thedecline inbirth rate lagsfar behind.And in that space between the faU in death rates andthefall inbirth rates, thepopulation explosion' takesplace . But history is equally conclusive that thosecountries whose death rates stood at around 15 per1000 in 1960 - which is around the average for lowincome countries today - have sinceseen their birthratesfall byseveral points for every onepoint fall inthedeath rate. Colombia's 6 point fall in death rates(from 14 to 8 per 1000) during the first two develop.ment decades was answered by a 15 point fall in thebirth-rate (from 46 to 31 per 1000). Over the sameperiod, a three-point fall in Jamaica's death rate meanta ten-point fall inbirth rates and in South Korea a fivepoint faU in the death rate found echo ina 20 point faUin birth rates.

The commonly held view that reducing infantmortality only stores up more births and more troublefor the future is, therefore, a mistaken one. Meetingbasic human needs is not only necessary to preventhuman suffering in the present, but also to reduce thegrowth of population itself, thereby avoiding morehuman suffering in the future. Whether today's worldpopulation of 4.5 billion eventually stabilises at I0-11billion or 13-14 billion sometime around the end of thenext century depends heavily onwhat happens to birthrates in the last two decades of this century.Present and future needs,therefore, cryoutwith onevoice. And each decade into tha t future will see amagnification of either the successes or the failures ofthe world community 's response to the needs of thepresent times.This choice between compouod failure and compound success is made the more crucial by thenumbers involved We can aUowthe largestgenerationof children to grow up malnourished, unhealthy anduneducated in order to become the parents of anothergeneration of malnourished, unhealthy and uneducated children. Or we can accord to our children thepriority they deserve by increasing etTorts andresources to amaximum, rather than aminimum atthistime when such a large proportion of the world isyoung. ParadoxicaUy, the present sees the future at itsmost vulnerable.

In sum, bringing about a significant improvement inthe lives of children by the end of this century willcertainly needa significant increase in the resourcesavailable for tbe task and in the effectiveness withwhich they are deployed. But it is a question ofpriorities not possibilities. It is a matter of choice inwhich both reason and emotionargue for children,Andit is a crucial moment at which to decide. For betweenthevicious and thevirtuous spiral, a choicemustnowbe made.


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Wanted: more benefits per dollarfor children

THE PLEA for priority for children - and forresources - has been made. But if another'realism' dictates that the resources availablenationally and internationally formeeting the needsofchildren areto remain close to present levels then theonly possible response is to seek to increase the ratiobetween resources and results. Somehow, ways mustbe found to get more development per dollar.Learning from experience, better use of availableknowledge, wisdom, research, and most important ofall, the will-these are the qualities which can convertadditions to economic resources into multipliers ofhuman benefits. And, in an increasing number ofcases, social improvement programmes arecoming tobeseennot asanInevitabledrain onnational budgets,noreven as just cost-effective welfare expenditures)but as productive investments in themselves.In the United States for example, ithas beenshownthat for everySI which government invests inrehabilitationfor thedisabled, 59 comes back intaxes paidbydisabled people who get jobs as a resultIn Egypt, the ten-year campaign to control thewater-borne diseaseknown asschistosomiasis is likelyto savea multiple of the investment in curative costsand lost nroductivity,In Venezuela,the governmenthas estimated that itsscheme to bring water and sanitation to large areas ofthe country willpay for itself five timesoverwithin adecade.InNew York, a recent study has concluded that aninvestmentof52.7 milliona year to improvepro-natalcare for low-income women could save between $10million and 512 million a year in high-cost intensivecare for premature babies - notincluding thesavings inlifelong support for children born with mental orphysical disabilities.Internationally, the successful campaign to eradicate smallpox, to which the U.S.A. contributed 550million, isalready saving the United States more thandouble that amount each year in immunization, quarantine and surveillance costs.In 1981, the ratification of the WHO/UNICEF'International Code of Marketing of BreastmilkSubstitutes bytheWorldHealthAssemblyrepresentsone of the greatest opportunities of recent times toeffectachange which wouJd combine improvements inhuman life with reductions in economic costs. Theimprovementfor infants can be illustrated in a singlefact - because of the nutritional and immunologicalproperties of mother's milk, those who are breastfedfor less than six months, ornot at all, are fiveto tentimesmore likelytodie inthesecondsix monthsoflifethan thosewhoare breastredformore than sixmonths.But for a Third World currentlyspending51 billionayear on infant formula products, and for low-incomefamilies spending53.50 outofaweeklywageof515 tobuy it for their children, theswitchfromthe promotionof bottlefeeding to the promotion of breastfeedingcould also mean a very significant economic saving.The scope forsuch combinationsof social progressand economic gain is clearly far from exbausted. It

cannot make economic sense for one third of allchildren's hospital beds in the developingworld to beoccupied by children sufferingfromcheaply preventable diarrhoeal diseases. I t is neither socially noreconomically acceptable to have 500,000 cblldren ayear being affected by poliomyelitis when 20,000shots of vaccine costlcss than 51,000. Nor is iteitherhumane or sensible to have aUowed over500 childrento lose their eyesight every day during 1981 wbenVitamin A tahLets costing only a fewcents could haveprevented itMeeting the mostbasic needs of the majority of theworld's children is a lessdirect and self-contained taskthan theseexamples imply. Butin thewider arenas ofnutrition, heaLth care and education, ways have to befound of using human wit and wisdom as much asmoney itself in bringing about improvements in thelives of the world's children.Sucb breakthroughs rarely happen by accidentTheyhappen byaninteraction between theexperienceof the past, the opportunities of the present, andincreased priority to the needs of children and lowincome families- It is that interaction whichUNICEFseeksto catalyse. And it is to thatexperience, and tothose opportunities that this report now turns.Recruiting en ermy of pereprofe..lonelsIn the task of providing basic services to meet thegreatest needsofthegreatest numbers, past experiencesuggests that an army of paraprofessional development workers - backed bymore specialized government services and stimulating the people'sowninvolvement inthecreation of those services - isprobably theonly way forward for the I980s.From onepointof view,the useofparaprofessionalsis an economic necessity. To train, equip and install afully qualified medical doctor in every Third Worldcommunity (even i f such doctors were prepared toserve there, which the majority are not) is an impossibility for tlte foreseeable future.From another point of view, the use of paraprofessionals is also more appropriate. The essentialrequirements of 'health for all' as setout by theWorldHealth Organization, forexample, are: 'adequate foodand housing,with protection of houses against insectsand rodents; water adequate to permit cleanliness andsafe drinklng; suitable waste disposal; services for theprovision of ante-natal, natal and post-natal care(includingfamilyplanning); infantandchildhoodcare,including nutritional support; immunization againstthe rnejorinfectiousdiseases of childhood; preventionand control of locally endemic diseases; elementarycare of all agegroups for injuryand diseases; and easyaccess to sound anduseful information on prevailinghealth problems, and the methods of preventing andcontrolling them. 'Theappropriate response to such health needs is notto devote available resources exclusively to thetrainingofmoredoctors to curedisease. It is a combinationof socialand economic development plus the training

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of literally millions of primary health care workersorcommun.ity developmen t workers whocan advise onnutrition, water, hygiene and waste disposal; providematernal and child health care, promote breaslfeedingand advise on fami lyplanning; organize immunizationcampaigns;workwiththepeopletowardspreventativepublic health; deal with common local illnesses andinjurie s; and refermore serious cases tomore qualifiedpeople.From yet anotherpoint of view, the use of paraprofessionals'is also a virtue . Even intheindustrialisedworld there istodayagrowingdisillusionmentwiththeover professionaHzation of social services. Sweden,forexample, is nowrequiring two outofeveryfivenewdoctors to commit themselves to primary health careand general practice. And inFinland the proportion ofthe national health budget allocated to hospitals hasfallen from 55 per cent to 43 per cent whilethe proportionspentonprimary healthcare centres- governedby locally elected health boards - has increased from11 per cent to 24 per cent In the Netherlands, whichbas achievedoneofthe lowest infantmortality rates inthe world, the greatmajorityof babies are delivered athome and attended by mid-wives at a fraction of thecost of births inmost industrializedcountries.In the Third World, paraprofessionals chosen fortraining by and fromthe communitieswhich they willserve are likely to bemore knowledgeable about localskillsandresources,more sensitiveto localculture andtradition, and more at home with, and acceptable to,those whom they will serve.In this way, paraprofessional developmentworkerscan blur the alienatingdistinctionbetweenexperts aodpeople and helpto involverather thanexclude thepoorfrom the process of change.Participation: the foundations ofdevelopment[f the potential importance of paraprofessionaldevelopment workers is one ofthe 'legs' ofa strategyof'more development per dollar', then the concept ofpeople' s participation is the other. Indeed without theorganized participation of the poor, no communitydevelopment project has more than the dimmest hopeof lasting success. I f, amid the scattered hopes of afailed development project, there were a tittle ' blackbox' to record what had gone wrong. it wouldalmostalways turn out to bethe case that, somewhereon theway, the people for whose benefit the project wasintended had found better things to dowith their time.That is why 'people's participation' is currently themost popular phrase in the dictionary of developmentAnd allbough it sometimes seems that the concept isonly kept aloft by the hot air of rhetoric, it too haspartiy arisen because of financial necessity.l'robablyonly throughcommunityparticipationcanprogress in public hygiene, water supply, and safesanitation be made and maintained on the scalerequired tobringabout significant improvements inthequality of life.InMalawi, forexample, pipedwatertoday flows inawater-scarce region for 150,000 villagers wbo them

selves dug the trenches, laid the pipes, and built theconcrete apron s and constructed the soak-away pits.Through their involvement in the construction of thesystem, costswerekeptdownto$3 per-personserveda smallfraction of the normalconstruction costs - andthemaintenance of thesystemisboth more competentand more likely.In practice, participation in the process of changeisprobably the exception rather than the rule. Butwhere

it is to be found, its virtues arealways to be seen.As the 1981 World Development Report from theWorld Bank points out, for example: 'The quality oflife for the bulk of the Chinese people is strikinglybetter than inmost low-incomecountries.' Looking atwhat lies behind this achievement, the Bank concludes that ' every level of society fromthe productionteam to the commune to the national level plays arole in providing social services. ProductionBrigadesmay finance the training of one or more " barefoot"doctors, who provide primary health care and oftenparticipate in the Brigade's work as well. State sub-ventions pay forsome of the programme, but participating groups also provide support, and participate indecisions concerning them. 'Of equal importance is individual participation. Amother who knows tbe benefits of breastfeeding or ofboiling contaminated water before drinking, forexample, greatly reduces lbe need for subsequent andcostly curative measures.Butthenecessityofpeoplc'sparticipationcansometimes obscure the fact that being involved in thedecisions and processes which affect one's own lifeisan end as well as a means and thatpeople's participationtherefore has adoublevalency withthedevelopment process. As Denis Goulet has observed:'Development is not a clusterof benefits"given" topeople in need but rather a process by which apopulace acquires greater mastery over its owndestiny.'This virtue, as distinctfrom thenecessity, of participation is, again, increasingly being rediscovered inthe industrialized world itself. Whether it be throughself-help preventative health, or the growingof naturalfoods, or sweat-equity housing, or home-energysaving, aneven larger number of peoplearebecomingre-involvedintheprocess ofmeeting moreoftheirownand their family's needs.And as this process of re-involvement gets underway, thatsame combination of financial and humangains which is so crucial to progress of lbe developingnations, isbeginning to showitselfin theindustrializedworldOn the food front, for example, American citizenssaved$ I4 billion in1977 bygrowingvegetables ratherthan buying them. For the average gardener, thatmeant a saving of $375 a year in addition to thebenefits ofmoreexerciseandbetter food. In health, theUniversity of California' , Self-Care Programme fordiabetics has balvedthe incidenceofdiabeticemergencies over two years whilst saving $1.7 million inhospital and patient fees.Paraprofessionals and people's participation therefore represent virtue as well as necessity. But as anapproach to development, there are those who accuseit of making the former out of the latter.It might, for example, be said that primary healthcare workers are merely the lowest andcheapest rungin a 'deliverysystem' directed from thetopdownwardsand designed to provide a second-class service to thepoor inorder to contain the problemof poverty and soavoidchangeinthesociety of which thatpoverty is apartIn some instances, this is undoubtedly true. It is stillthe case that, across the Third World as a whole, 80per cent of health budgets are being spent on doctorsand hospitals for the urban fewwhilst primary healthcare workers are packed off to look after the ruralmany. In such cases, the conceptof people's partic ipation, similarly, is usually just a fancy name formaking the poor responsible for their poverty.Inother cases, thepattern ofparaprofessionals and


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people'sparticipation intheprovision ofbasic servicesis seen not as an end but as a beginning, not as aminimum service but as the maximum whichcan beachieved at any particulartime and atany particularplace,notasa separate healthserviceforthepoorbutameans by which the exi sting health services- includingdoctors and hospitals - can be geared to the needs ofthe poor. And however loosely the term ' barefootdoctor' is nowadays used, China's primary health careworkers gai n significantly in both credibility and effectiveness through being able to refer the poorest ch ild ina rural communeup through a systemwhich can leadto the mos t sophisticated clinic in Beijing if that is theappropriate levelof treatmen t forhisorhercomplaintThe training, referral, andsupport services impliedin this re-gearing of health services to serve themajority, should alone dispel any notion that primaryhealth care is a low quality solution. To bring basichealth servicesto everycommunity in the poorworldeven by the most appropriate and efficient methodspossible- willmeana verysignificant increase in theresources available for the improvement of humanhealth. Such an increase in 'human capital' wouldalmost certainly pay large dividends in economicgrowth and development (a health scheme for workersin Indonesia, for example. was seen to raise productivitywithin eightweeks)butfrom thepointof viewofhuman health alone the efficiencyof the primary healthcareconceptresides notinanyabsoluteloweringof thecost but in ways of using additions in resources toproduce multiplication in benefits. And without doubt,basing community development strategies on participation and paraprofessionalism will lead to moredeve lopment per do llar.Synergisms: meking one plus one eque'three

One of themostobviouslessons of the developmenteffort is thatprevention is almost always morecosteffectivethancure. And concernforthe prevention ofillness means thatprimary health care is inseparablefrom such issues as agriculture , housing, sanitation,watersupply, education, femaleemancipation, or thequestions of work and wages which are lite basis of anadequate diet and a healthy people . The best trainedand bes t su pported primary health care workers therefore cannot helpbutbecome communitydevelopmentworkers. And it is thiswider scope of the communitydevelopment worker which offers- another majoropportunity for increasing the effectiveness withwhichavailable resources are applied.

Poverty, like a self-sharpeningknife, finds lite meansofmaking eachof its disadvantages reinforce theotherA disease like measles, for example, can carry a 50-50risk of death if contracted by a child who is alsomalnourished. But the converse is also true . Andalmostall improvements in thewell-being of a com-munity will tend 10 compound each other 's benefits.Immunization programmes , for example, bothstrengthen and are strengthened by the other elementsof basic health care. "Simple andlow-costservicesactsynergistically 10 break lite vicious cycle of malnutrition and infection,' says Dr. Ralph Henderson,D irector of WHO's Expanded Programme of Immunization. 'and the success of anyone service inreducingmorbidity and mortality is expected to help toconvince lite community of lite worth of all lite otherservices.'Of particular importance in the International D rinkingWater Supply and Sanitation Decade( 1981 -90) isthe syne rgistic relationship betweenclean water and

health education. Water may be clean when it isbrought to lite surface by lite new handpump, forexample, but i f i tgushes into a bucket linedwith germs,or if lite c loth placed on top of the bucket to preventwaterfrom spillingoutonthewayhomeis brown withfiltereddirt, orifthe wateris stored forhoursinanopenja r near lite door, then its benefits are likely to bered uced by the time it is used. Counting lite number ofwells drilled or standpipes installed, is, in such circumstances, only superficially satisfying. And time mightbebetter spent contemplating theshiftof, say, ten percentof the investment inwatersupplyto a corresponding programme of heallit education designed to ex trac tmaximum benefit from that investm entA eat's cradle of such synergisms links almos t everyaspect of development female literacy catalysesfamily planning programmes; less freq uent pregnancies improves materna l and child health; improvedheal llt makes lite most of pre-school or primaryeducation; education can increase incomes andagri-cultural productivity; better incomes or better foodreduces infant mortal ity; fewer child deaths tend 10leadto fewer births; smaller families improve maternalhealth; healthy mothers have healthier babies;healthier babiesdemand more attention; stimulationhelps mental growth; more alert children do better atschool . . . andso it continues in anendless pattern ofeither mutually reinforcing or mutually retardingrelationships which can minimize or multiply thebenefits of any given inpu tFor such synergisms to work positively, and soincrease the ratio between results and resources, theintegration of services is obviously necessary. Andthat brings us right bac k to lite broad ra nge of liteprimary hea lth or community development worker'sconcerns

Far from the village, separate government departments foragriculture, health, education and employmentmaymake theirseparate servicesavailable. Butthe community development worker livingwith theproblem of underdevelopment at village or communitylevel has no temptation to see nuuition, health, education and poverty as separate issues - and everyoppor tuni ty 10 feel the pulse of those inter-relationships which can convert ' inputs' into the beginnings ofdevelopment A recentstudyof six.mtijor internationaldevelopment projects has noted; 'Integration is usually achieved more easily at lite lower echelons of thehierarchy than at lite top' .

Linking whet science knows to whetpeople needIn devising ways (0 extract more 'development perdollar', science has made many breakthroughs in bothincreasing effectiveness and reducing costs of thetechnologies involved in fighting poverty. And its failure to rulfiU its promise is not so much a failure ofscience itself, but of social organisation, a failurepoignantly identified in R.F . Fendalfs epitaph onTwentieth centurymedicine: 'Brilliant in its scientific

breakthroughs, ingenious in its technological invention, andwoefulJy ineptinits applicationto thosemostin need.'Nowhere is that gap between what science knowsand what peop le need more tragically eviden t litan inlite esti ma ted five milli on young lives claimed eachyear by diarrhoeal d isease.Repe ated bou ts of diarrhoea drain life-sustainingfluids and salts out of the body. P revention depends

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upon a combination of nutrition, food hygiene, watersupply and sanitation. But as all of these are severa lyears ifnot decades away from thepoormajority. aneffectivecurative treatment is necessaryifmillionsoflives are to be saved in the meantime .In the 1960 5, the 'cure' was rehydration fluidadministered through an intravenous drip by trainedmedical staff in hospitals or clinics. In otherwords, itwas a cure 'woefully inadequate in its application tothose most in need.'Since the early 1970s, there has been another way.In laboratories in India, Bangladesh and the UnitedStates, a rehydration t.reatment has been devisedwhich costs only a few cents, is based on easilyavailable salts and sugar, is madeup in the homebymixing with boiled water, and is administered bymouth rather than by intravenous drip.Tested under 'worst possible conditions' in emergency camps, thenew treatment cutchilddeaths fromdiarrhoeal disease by 90 per cent ' Veryfewshould dieif treatment can start early and, preferably, at home:says Dr . Dhiman Barua,WHOMedical Officer for theDiarrhoeal Diseases Programme.In the million villages of the Third World, doctorsarenotgoingto beathand to begintreatment'earlyandat home'. Primary health care workers could be.The aim of WHO and UNICEF is to make oralrehydration treatment available before 1983 to at leasta quarter of all children under fivewbo are affected bydiarrhoeal disease. Scientists can devise the Correctformula of salts; doctors, hospitalsandclinicscan runtraining courses and hold stocks; but only tens ofthousands ofprimary health careworkers canmakethetechnique available to individual parents as and whenthey and their children need itIntheorganizationof immunizationcoveragewhich

requires three injections for each infant and two foreach mother, in the weight checking of pregnantwomenandnewborn babies which is themostsensitiveindicator of either their well-being or their need forhelp, in the earlydetectionofdisabilitywhich iscrucialto eitherprevention or reduction of its impact on thenormal lifeof the child, it is the on-tho-spotpresence ofpeople trained in basic health knowledge and backedby specialized services which can extract the maximum human benefits from scientific investment bymaking its breakthroughs less 'woefully inept' in theirapplication to those most in need.Beyond the theorySuch a summary of what primary health care cando inevitably elides itscomplexities intotoo smooth anoutline. ' To build a workable and affordable healthcare system which will serve the great majority ofneedy families' says a recent analysis of the LampangProject in Thailand "is a considerably more complicated, time-consuming and expensive undertakingthan is generally realized by those who have notactuaUy tried.'{Nevertheless,' the report concludes, 'it has to bedone because this is undoubtedly the most effectiveand feasib le way- probab ly the only way- tomeet the

crucial and long-neglected basic health needs of thepeople.'That is why primary health care is no longer anuntempered theory but an idea going into action, in aUits various permutations, across thedevelopingworld.In Africa, Botswana is training one 'family welfareeducator' for each village; Ethiopia is retraining28,000 traditional birth attendants and communityhealth workers; Malawi is trying out a 12-week

primary health care courseacross one of its regions;Somalia has trained 1,800 community health workersand plans to have two for every village by 1985; theSudan has trained over 1.000 community healthworkers forsettledcommunities and 176 fornomadicgroups; Zimbabwe is building on its 1,000 formermilitary paramedics in order to create nation-wideprimaryhealth care; Niger has trained 560 communityhealth worker. with specific emphasis on reducinggastro-entericdiseases inIwoState;inSenegal,Benin,the Congo, Niger and UpperVolta, the idea of 'healthfor all through primary health care' - as propounded byWHO and UNICEF at the Alma Ata Conference in1978 - is now being tested against the realities of thecontinent's problems.In Asia, India has already trained 100,000 community health workers and retrained 150,000 traditional birth attendants in its attempt to provide oneprimary health care worker for each of its 580 ,000villages; Bangladesh is training one community healthworker for every 1,000 people in six test areas;Indonesia is experimenting with the training of'prokesas' (voluntary health workers) chosen by eachblock of 30 families; Thailand has already trained11,000 village bealth workers and 112,000 ' villagehealth communicators' who now serve 2S percent ofits Population; Nepal plans to extend primary healthcare to all 27.000 communitie s; Vietnam's com-munity development workers, selected andpaidforbytheir own communities, are now backed by 8,500health centres across the country; and inChina, theoriginal 'barefoot doctors', backed by an increasinglysophisticated medi caJ service, areproviding theappropriate level of care - from bandages to brain surgeryfor almost a billion people at a cost of less than $7 perperson per year.In theAmericas, theprimary health care approachofCuba and CostaRica have achieved infant mortalityrates among the lowest in the ThirdWorld; Nicaraguais now training 2,000 community health workers andhealth volunteers and making oral rehydration treatment locally available to more than 100,000 children;in Jamaica, Colombia, Ecuador, and Panama,primary health care experiments have been launched.And in the Democratic Republic of the Yemen,Saleh Harnshali, a newly trained health guide, hastoday been caUed away from the orchard where heearns his living. He has beensent for by amother whohas become desperate about her one-year-old

daughter. The child has had diarrhoea for two days andis obviously failing.As Saleh hurries from the field. hepasses by many of the men and women who elecledhim, a few months ago, to be trained as their healthguide. Some of them are burning garbage as heapproaches the edge of the village.Within a minute or two, he arrives at the child'shome and stoops throughthe stone doorway. The girl islying on a matt ress on the floor. Immediately he asksfor boiled water to be brought and unslings the satchelfromhis shoulder. Tearingopen a foilsachetofwhatheknows as 'UNICEF Salts' he mixes the powder withfour Coke bottles full of water. The mother looks onanxiously as Saleh carefuUy transfers the liquid fromone clean bowl to another tomakesurethatthe saltsare fully dissolved. Spluttering, the child drinks thefluid from a clean tin mug. She will certain ly live. Twoyears ago, Saleh's own one-year-old daughter exhibited the same symptoms. He r grave is a smallmound of sandstone rocks on a hill just outside thevillage. At that time, Saleh did not have his three weekstraining nor ten cents worth of salts.


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Investing in children -social justice and economic senseTHE community level, paraprofessionalsand people involveme nt are the most important ways in which the 1980s can extract moredeve lopment per dollar and improve the lives of theworld's children even within the financial constraintsof the years to come. But implemented in isolationfrom changes in national and international priorities,they are unlikely to fulfillmore than a fraction of theirpotential or to be the beginning of the end for absolutepoverty. For a broader and ever more powerfulsynergismalso exists between improvements in health,nutrition, education, and improvements in social andeconomic development- in productivity by and for thepoor majority .But as the budget of the ThirdWorld's governments

- and the aid flows they are likely to receive from theindustrialized world - are also severely affected byworld recession, ways must also be found at thenational and international level of making every dollargo further,

Basic needs and a new economicsAgain, the lessons of the development effort inrecent years point to one outstandingway inwhich thismight be done. In summary, that lesson is that thecreation of productive employment opportunities by

and for the poor, and of social services designed tomeet thei r needs; will not only alleviate poverty nowbut will actually help to acce lerate economic growthitself.The implicit proposal - a direct rather than indirectattack on absolute poverty through the provision ofservices and employment opportunities designed tomeet the needs of the poor majority - ran counter tocontemporary economic wisdom. Such approaches itwas said were inefficient and would lead todecreases ininvestment and to a slowing down of the very growthwhich made the expansion of such services possible.But as the 1960s became the '70s, it was clear that

the persistence of poverty represented not only acontinuing human tragedy but also an undermining ofthe process of growth itself.Labour is as important as capital in the process ofincreased production. And a malnourished, unhealthyand illiterate population was therefore a serious constraint on productivity. From this point of view, socialservices which build up ' human capital' are not consumption but investment Humanitarian concernthereby acquired economic respectability. Says formerWorl d Bank President Robert McNamara: 'Humandevelopment - educat ion and training, better helathand nutrition. and fertility reduction - are shown to beimportant not only in alleviating poverty direc tly butalso in increasing the incomes of the poor and GNPgrowth as well'In agricultu re - on which approximately threequarters of the Third World's people depend for thei rlivelihood - the advantages of redistributing land inorder to invest in the sma ller farme rs and the poorerhouseholds has now proved itself in many developingnations where the smaller fanners have effective

access to credit, markets, technology, education andhealth facilities. In general, the larger the farm, the lessintensively it is cultivated, the less labour it uses, andthe less per acre it produces. After land reform inTaiwan, for example, average yields per acre rose by80 per cent And in South Korea, one of the reasonsbehind its increased agricultural productivity is thatbetween 1945 and 1965 the percentage of ruralhouseholds who worked on land which they themselves owned rose from 14 percent to 70 percent Suchlandholdi ngs, as in Taiwan and Japan, averaged onlyone hectare in size. And in all of these cases, thenumbe rs of agricultural workers per 100 acres rosesharply as did the number of days worked by eachperson - thereby increasing their incomes and theirability to feed, educate and otherwise care for theirchildren. We have only recently begun to recognisethat the difference in agricultural productivity betweendifferent countries and regions is not primarily aquestion of their cultural background, although thathas some impact, but of the organ isation of theiragricu lture and of whether or not fanners have incentives and access to support systems. 'The outstandingsuccess of the 1970s has probab ly been the improvedproductivity of small farmers,' says the 1981 WorldDevelopment Report. ' Their extra output has been thekey to impressive growth in such countries as India,Indonesia. and Malaysia' .Greater atte ntion to the allocation ofassets, servicesand opportunities for poorer households and smallproducers can increase the efficiency with whichresources are used. It can help to meet needs now. Itcan help to increase productivity. It can help to ensu rethat the benefits of that increased productivity accrueto the majority. And, for the reasons discussed elsewhere inthis report, itcan help to slow down the rate ofpopulation growth and thereby assist development inthe future as well as in the presentIn theory, then, the approach of trying to meet basicneeds - for food, health-care, education and jobs represents increased value for development expendi

ture.In practice, comparisons across different developingcountries also show that economic growth in thosecountries with high life expectancy and literacy ratesgrew faste r in the 1960s and '70s than those wherehealth and education services lagged behind. Many ofthose countries and regions which achieved sustainedper capita growth in GNP of 6% or more during the1960s and 1970s- such as Japan, Singapore, Taiwan,Hong Kong, Romania or South Korea- made a greaterthan usual effort, and with greate r than usual effectiveness, to advance the well-beingof low-income familiesand their children. Sri Lanka, long chastised byconventional economists for its profligate 'consumption' through social services in the J9505, was seen tobe succeeding in bringingabout lower infant mortali ty,longer average life expectancy, higher literacy, andlower birt.hrates than either India or Bangladesh whilstat the same time seeing its economy growmore quicklythan its neighbours.In 30 developing countries surveyed by the WorldBank, primary education was found to be the most

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productive investment opportunity available- able, intime, to yield a hard economic return of approximately24 per cent In the same study, the productivity offarmers with four years of primary education wasfound to be 13 per cent higher than that offarmers whohad never attended school (where the necessary farminputs were available in both cases).China, South Korea, Tai wan, all gave their evidencethat investing in people through services designed toreduce poverty could reinforce rather than detractfromthe process of growth itself over a time-span of adecade or more. And in all of these cases.. the International Development Strategy's social goals of reducing, in all countries, infant mortality to 50 per1,000 or less, increasingaverage life expectancy t060or more, and reaching a literacy rate of at least 75 percent, have been achieved at a level of GNP per headwhich is well within the range of all developingcountries by the year 2000. And in all, the PQLI(Physical Quality of Life Index") rating is well abovethe average for middle-income countries which haveper capita incomes several times higher than a China, aKerala, or a Sri Lanka.The potential of such ' human development' strate-gies for increasing the efficiency of the developmentprocess - and hence forachieving a significant improvement in the lives of children even within the economicrestraints of the late twentieth century - has thereforebeen demonstrated in both theory and practice.

Political will and changing prioritiesAlmost "II of these ways of achieving more benefitsfor children and mothers per dollar - whether they bebroad strategies of switching emphasis to humandevelopment or more detailed plans to build 50 health

centres rather than one hospital - require changes inpriorities. And such changes are not easy in view ofestablished interests in existing patterns.For they are strategies which contribute to anddepend upon the greater priority to low-income families implied by a 'bas ic needs first' approach todevelopmentAll of the policies designed to meet such needs switching the emphasis from universities to primaryschools. from hospitals to primary health care, fromcities to rural areas, from large estates to small farmsare policies which bring more benefit s to the children ofthe poor and can, at the same time, accelerate a

nation's economic growth. It is not, in most cases, aquestion of dismantling hospital s., it is a case of re-harnessing bospitals and doctors to the needs of themajority - often through the provision of training,referral and back up services to primary health careworkers.But while there can be little doubt that switching*The PQLI fuses the. rates of literacy, in/ant mortality andlife expectancy at age one into a single composite index Wlha high oj 100 and a low of zero. For each 0/ these threeindividual indicators, a rating oflOO represents the highestpoint whichany country in the worldcan expect toachievebythe year 2000. A rating of z r at the other extreme,represents tht lowest rate prevailing anywhere in the worldof 1950. Onl! hundred on the lift expectancy scale. f orexample. represents the 77-year average which a countrylike Sweden can expect to reach by the end of the century;whereas zero represents the l8-year life expectancy whichprevailed in very poor countries 30 years ago.The PQLI gives equal weight to all three indicators andaverages them to provide a measure of the physical wellbeing of a gi ven population.

priority to the majority ofchildren and mothers rendersmore efficient the process ofusing available resourcesto improve the quality of life, such decisions areultimately politicalThe political will requi.red to invest in the poormajority is perhaps the scarcest resource of all in thestruggle for world developmentThere can be no artificial substitutes for that will tocreate or to permit the efficiency ofgreater equity. Butit is a process which the industrial world can facilitate

bychanges inthe terms of trade and levels ofaid whichcould help to increase the resources available to thenations of the developing world for financing projectswhose main beneficiaries are the poor and the powerless. International broadening of economic opportunity can therefore reinforce the same process withinnations.But the political will required to do so seems just asscarce. The attempts to create that will - throughspecial sessions of the United Nations GeneralAssembly, through the meetings ofthe United NationsConference on Trade and Development, through theNonh-South taJlrs inParis, through theBrandtCommission and over the summits of Ottawa, Melbourne andCancun - have been binged partly onmoral argumentsand partly on the idea that the transfer of resources tothe 'developing south is also a method of regeneratingthe economies of the industrialized north. Such astrategy echoes, at the international level, the ' neweconomics' of the basic needs approach to development in its suggestion that investing inthe productivityof the poor perhaps could be as good for the worldeconomy as investing in the productivity of poor communities could be good for national economies.In practice, however, trade policies which restrictthedeveJoping world earnings - and aid policies whichdirect more than 50 per cent of official developmentassistance to the wealthier developing countries- put abrake on progress towards improving the lives of theworld's children .

Technology and .ocial organizationThe ' equity factor' is therefore important at bothnational and international levels in determining howmuch development can be derived fromeach availabledollar. But at the local or community level, that sameequity factor has to be one of the key considerations inprojecting the efficiency with which any development

project involves and benefits the poor. Otherwise awell-drilling programme which begins as an attempt toimprove the health of the poor can end as little morethan a subsidy to the landowner; the launch of a newhighly-yielding crop variety which begins as an etTortto increase nutrition can end by increasing the size offarms and the numbers ofthe landless; the introductionof a tractor which begins as an attempt to enable largeracreages to be ploughed can end 8S onerous extrahours in the fields for the women who do the weedingand the gleaning.At every level of the development process, suchchoices have tobe faced. To move forward inthebelief

that money and technology can work independently ofsocial relationships is to repeat 8 formula which hasbeen tried and failed Technical solutions can be, andoften are, brilliant solutions to a part of the problem.And more scientific research is needed on the healthand agricultural problems which affect the lives of Ibillion people yet which claim less than I per cent ofthe world's research budgets in those two fields. Butwhen science and technology are treated as the


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solution to the whole, they Ire, to borrow an imagefrom Zen, like the sound of one hand clipping.To move forward, and to mike what has beenachieved in the realm of techniquemore trulyuseful to

the lives of the majority, it will benecessary to tumagain to face the irreducible problems of political andsocial relationships - whether we are talking ofpeople' s participation or economic inequa lities - withwhich humanity has always had to struggle but fromwhich dramatic advances in techniquesseem to havegiven us a temporary respite.Unlike technical difficulties, such problems are notsusceptible to the impositionof centralized solutionsworked out by the few and applied to the many. Theydepend upon a decentralized diversity of approachesandexperiments and are based asmuch on accumu-lated wisdom as on breakthroughs in know-how.In other words, these are the really difficu lt problems of development And they underlie many of thefailures and the disappointments of the developmenteffort in recent years.As long as development is viewedas 8 question ofscientific intervention by experts as opposed to aquestion of social organization by people, such di. .appointments are as inevitable as thediscouragementwhich follows them.And because disillusionment is as great a threat toprogress as is economic recession, this report. whichhas focused on the ratio of resourcesto results, shouldconclude by re-calibrating the criteria by which'results' are judged in order to takeaccountnot just oftargets aimed forand resources available, butthe factthat development is about social organization. anddepends upon a process whose complexities we areonly just beginning to understandLearning from development'.diNppolntment.

Fo r too long now, the Third World has beenportrayed to the industria lized world as a uniformentity within which on e simple forroula for deve lopment can be everywhere applied T o say thatlndia, forexam ple, has 500,000 villages conjures up in the mindnot 500,000 villages hut on e village replicated500,000 times. Yet no community in th e deve lopingworld is less complicated than any community in theiodustrialized world. All communities have culturalandsocial norms, vestedinterestsandclass divisions,loyalties an d jealousies, leadership patterns an dchange procedures, and established habits ofbody andmind Al l communities are affected by psychologicaland cultural accommndations to what has been possibleornecessary inthepast Andnocommunity is ablank slate on which outside experts can write prescriptions for improvementPerhaps because of theexigencies of raising funds,orbecauseno one likesto see achievements faJl shortofhopes, there has been inthe past a great reluctance toacknowledge disappointments in the field o f development An d the public image of its workings becomeseriouslydistorted as a resultThere is still, for example, an abiding notion in theminds of many thatan expertneed onlygo into a villageor a slum and impart his wisdom for it to be unanimously adopted to the instant benefit of all concernedIn view of comparable efforts in the industrializedworld, this is a strange misconception. For manyyears, experts possessed of knowledge have been usingmuch more sophisticated communications technologies to reach a muchmoreeducated audiencewiththemessages thatcigarette smokingis injurious to the

health, that sea t belts save lives, that women shouldhave equalrights, thatthepreventionof'envircnmenralpollution is cheaperthanits cure, that lowerautomobile speeds save fuel and lives, tha t obesity is a bealthhazard, that the over-prescription of the abuse ofdrugsis not to be recommended, or that drinldng and drivingis anti-socia l Yet the conveyi ng of these messages hasnot automaticallyorinstantly resulted inmass changesof behaviour, and, indeed, many of these 'logical andobvious benefits' have had to be assisted by legislationin order to increase their level of public acceptance.It would be too generous to credit the Third World

with a much greater capacity for instantchange, anditis therefore reasonableto lowerthepretencethateverysingle cent allocated by governmental or privateagencies to the taskofworlddevelopment is instantlytranslated into substantial and lasti ng benefits for thepoor. Such a deception may warm the conscience ofthe dono r, but it bears little relationships to thecomplexities of poverty and deve lopmen tIn this context, the heresy of development projectswhich are less than 100 per cent successful is easierboth to acknowledge and to learn from.In adultl iteracy campaigns, for example, it has oftenbeen found that hal f of those who enrol do not complete the COl1{Se and halfof those who do fail to becomeliterate.In outritional education, the World Health Organization has commentedthat'many of these efforts havebeen unsuccessful in improving dietarypractice'.In women's training courses designed to impartincome-earning skill, it is not uncommon to find thatless than ten per cent of the participants are actuallyearning any money as a result,In water programmes, UNICEF's own researchpublication reports that'in one example, afterthefirst

year of its implementation, up to 80 per cent of thehandpumps are reported out of order.'In employment creation schemes, a recent study bythe International Council for Educational Development reports that'the record of success has generallybeen disappointing'.The six-nation study referred to her e was in factfinanced by major foundations such as Ford andRockefeller and by aid agencies of the governments ofthe Netherlands and the Uni ted States, as weU as byseveral interna tional voluntary organizations, for thepurpose of analysing what had been learnt from thefailures - and the successes - of projects designed toimprove conditions in rural areasof theThirdWorldIn his introductory overview to this study, projecteditor Philip H. Coombs sums up the dangers ofregarding developmentas somethingto bedeliveredtothe grateful poor.'Themistaken assumption thatunderliesmany topdown programmes, is that villagers because theyare illiterates, areunintelUgent andmustbetreatedlike children. Hence the 'message' devised byexpertsat higher echelons often tendsto talkdownto the rural people, telling them what is ' good' forthem (without really explaining why) and urgingthem to abandon various traditional practices infavour of innovative ones which the experts con-sider to be better.

'But in reality most rural people, far from beingstupid, haveacquired considerablewisdomthroughthe years of struggling for survival. They m ay clingto certain ill-founded myths and taboos that dothem more haem than good, but they also have avery practical sense and a great fund of localknowledge that exceeds that of the outsider. Their

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cautiousness about accepting advice from tout-siders' is usually well-founded; they have beenburned too often before. They may hstenpolitely tothem, but are unlikely to heed their advice - forexample, to alter their diet or to adopt modemfamilyplanningmethodsorsome agricultural innovation-until and unless theyare convinced in their ownmind, and by thei r own logic, that it is in their ownbest interests to do so. They are far more likely toacce pt the advice of a respected neighbour whomthey cons ider the local expe rt on a particular matterthan to follow the advice of outside specialists.'T hus much of the impetus for changemustcomefrom within the community. The problem is how tospark this impetus and the n how to get the community effectively organized for self-help, selfdirection and broad-scale change.'Such a conclusion may seem untidy, unsatisfyingand elusive. But all of UNICEF 's experience says it isclose to the heart of the problem. And however less' attractive ' that problem may seem than the kind ofproblem which can be solved in a laboratory or on acomputer or by a technical breakthrough, the development effort in the 1980smust again add ress itselftotheissues of social and political relat ionships if it is tobring about significant improvements inthelivesof theworld's children. The questionmark for human progress during the remainder of the century hangs notoverourability to manipulate external circumstance,but over our ability - intematlcnally, nationally andlocally- to create just and sustainable soci al relationships. And the greatest lesson of the last three decades,and the one which bolds out most hope of a betterfuture for the world's children, is that world development is notjust a process of technological interven-tion, but also of social organization, an art as well as ascienceUNICEF: Applying the I on.

In its attempt to assis t in this process, UNICEFitself has changed its methods of operation since itsinception 35 years ago. Then, almostthree-quarters ofits s taff were housed at headquarters in New York.Now, more than three-quarters of its staffare livingand working in the developing world And, wheneverpossible, UNICEF now works through nationalofficesand officers to find 'decentralised' solutions tothe ta sk of bringing more benefits to children for everyavaila ble dollar.

The lessons which have been learnt over thosedecades and which bavebeen discussed in this report-lessons about paraprofessional development workers,about peoples participation, about the synergisticbenefits of integrated approaches, about preventionrather than cure, about the importance of socialrelationships as well as technological interventions have led to the'strategy of basic services' which nowguides UNICEF's work for children in over100 nations of the world. This ' bas ic services'approach isnota centra l formula for the imposition 0/development but decentralised strategy of parti cipationindevelopment And assuchit isbasedontrainingandassistingdevelopmentworkersto provide essentialservices to mothers and children in cooperationwithpoor communities thro ughout the world

The result is that- in the last twelve months alone UNICEF has helped to train over 115,000 healthworkers and to equip almost 43 ,000 bealth centres; totrain overhalfamillion village levelnutrition workersand expand nutrition programmes in over 130,000villages; to cooperate in almost I00 ,000 water supplysystems and in the installation of over a quarter of amillion sanitary latrines; to train over90,000 teachersand to equip 88 ,000 primary schools.

Work of this kind byUNICEF and bygovernmentalagencies needs to be backed by broader scale economicand socialpolicies whichconcentra tenational andinternationa l resources ontheneedsof theone-flfth ofthe world's people who today are the 'absolute poor' .And the more resources whicb can be made availablefor this investment through increased aid and morelibera l trade policies in industrialized countries, andthrough increased prior ity to the poorest in the doveloping countries , thesoonerwillabsolute povertybeabolishedBut this, the largest ever generation of childrencannot wait Their childhood, whicb is so threatenedby the darkness of today's economic climate, will nntstand stilltoawait the restoration of economic growth.For them action is needed now to shift priorities infavour of mothers and young children, to refme andimplement strategies for increasing the ratio betweenresources and results, and to make that most crucialinvestment in today's children and tomorrows world'Each generation should pay to its successors the debtit owes to its fore-runners, 'wrote James Connolly,'and by spending itselffor the benefit of its cbildren, thehuman face ensures the progressive development of

aU.

Documents

UNICEF: The State of the World's Children 1981-82