education and medical treatment.China's barefoot doctorsWhere the expansion of privateBest known for its use of "barefoot financed from four sources: an annual education and health care is notdoctors" at the grass roots, China's rural premium paid by members; charges for inconsistent with national policy,healthcaresystemhasseveralotherfaces the service; appropriations from the this would allow scarce govern--specialized urban hospitals serving the brigade's social welfare fund (collected ment funds to be concentrated onsurrounding areas, well-equipped county through a tax on each production team's the poor. But if the middle classeshospitals, and health clinics at commune income); and, sometimes, subsidies fromcenters. These facilities provide indis- the county government. invariably send their children topensablesupportfortheextensive coverage The annual premium, 1-2 yuan ($0.60- private schools, much of the necprovidedat the "brigade" level-catering 1.20) per person or 5-10 yuan ($3-6) per essary political support for hightoa large village or several small ones. family, depending on the locality, is a quality public education may beEach brigade sets up a program with considerable sum for peasants whose lost.financial support from the government; incomes average only about 100 yuanbut once established, it must be self- ($60) a year (only a small proportion One way of mobilizing privatefinancing (though the government may of which is cash income). The brigade's funds for education is by restrictinghelp in exceptional circumstances). A social welfare fund is a fixed percentage the number of places in publicmajority decision of the brigade members of its total income, so the contribution universities, maintaining highis enough to start or end a program; indi- from the fund to the health program standards there, and then allowingviduals can choose to join-and leave-it. depends on the brigade's income. Mem-China's 1.6 million barefoot doctors bers pay for each visit to the brigade the private sector to cater to those(roughly one per 600 people) operate at health station. In complicated cases, they who can afford it but do not succeedthe brigade level in rural areas. Many may have to go to the commune health in the stiff competition for theare women, selected by the brigade center or the county hospital. Charges places in public universities. Scholarmembersfor training, and supported by at the commune health center are nor- .. a. bthem during training (which usually takes mally paid out of the brigade's health ships to public universities can beplace in the slack agricultural season). fund; but patients attending the county provided for those who cannotAfter completing training, the barefoot or specialized hospitals must pay at least afford tuition fees. This has beendoctors return to their brigade, continuing part of the fees themselves. done in South Korea, where 72to devote part of their time to farm work. Like other primary health care systems percent of higher education enroll-Barefoot doctors are trained to use relying on community health workers, ments are in private institutions,both modern techniques and traditional China's has faced problems of credibilityChinese medicine-acupuncture and and training, and of uneven levels of while in primary education (whichherbal cures, for example. By combining service. Steps are now being taken to is virtually universal) 99 percentthe two, they increase acceptance of address these problems, including more of the enrollments are in publicmodem treatment and reduce costs-since emphasis on initial and in-service training schools.they prepare herbal medicines from locally of barefoot doctors. The intention is to . .grown ingredients. upgrade the services as funding and staff In some cases it is even possibleAs a rule, the brigade program is skills permit. to charge the better-off enoughI to subsidize services for the poor.In many countries, for example,lent example both of keeping costs of the educational system-were fees for private and semiprivatedown and of upgrading services also discussed earlier (see page hospital rooms are set well aboveas the economy grows-the Chinese 50). costs and the surplus used to subarenow providing their primarysidize poorer ward patients. Therehealth workers with additional Using resources other fhanare even better opportunities fortraining and better support. Restrict- national tax revenue this type of cross-subsidy in urbaning subsidies to those who cannot The state invariably plays a central water and sanitation systems,afford to pay for services can also role in education, health and nu- where the subsidy can be virtuallyhelp keep costs down (see pages trition programs. But it is by no automatic. The well-off are gen-62-63 for examples of how this means the only source of finance erally willing to pay more than thecan be done in nutrition pro- for human development. With the actual cost of the service becausegrams). But overly narrow targeting proper incentives, individuals, pri- the alternative to being connectedmay sacrifice some political support vate firms and other nongovern- to the public system is a privatefrom middle- and upper-income mental organizations can play an well or septic tank, at much highergroups-support that may be critical important role. cost.in establishing a program to reach Most food consumption, of Local resources can also reducethe poor, too. Various ways of cut- course, is privately financed. the financial burden on the center.ting unit costs in higher education Moreover, the relatively well-off In Tanzania in the mid-1970s, self--by far the most expensive part are often willing to pay for private help labor was equal to about 1074
percent of the development bud- developing world involve build- As people become more mobileget. The Tanzanian government ing such things as wells, schools and the cash economy more widetypicallyprovides construction and health clinics. But they do not spread, the strength of traditionalmaterials for projects, and the stop there: in many countries local self-help efforts may wane. Butlocal communities provide the people provide food and housing instead of providing resources inlabor. Self-help organizations exist for primary school teachers. It is kind, local communities can raisein many developing countries: one more difficult, however, to mobilize money (through local taxes orexample is Sri Lanka's Sarvodaya sustained support for recurrent charges) to support their efforts.Shramadana Movement (see box.) costs than for one-time efforts, such Like other forms of self-help, thisMost self-help projects in the as construction projects. can be stimulated by matchinggrants from the central govemmentin support of locally initiated andSelf-help in Sri Lankamanaged activities. In Kenya, forFrom small beginnings in 1958, the week leadership training course. On their example, the government assistsSarvodaya Shramadana Movement now return they beganforming what Sarvodaya harambee (self-help) projects thatemploys some 6,000 full-time workers calls the "social infrastructure"-groups meet official guidelines. But slugandreaches more than 10 percent of the for mothers, farmers and so on. Repre- gish administration in centralcountby's rural population. It has full- sentatives from each group made up thescale programs in some 300 villages, but Village Reawakening Council, which has agencies can suffocate local pariciisactive in another 2,500. It has organized initiated various productive activities, pation and self-help-enthusiasmeduca-ion, health, nutrition, sanitation such as growing bananas and passion and initiative may wane if deciandhousing; set up agricultural and fruit as cash and food crops, and set up sions take too long or promisedhandicraft programs; and is starting to a cooperative store, assistance does not arrive on time.promote other small-scale rural industries. In the community center built dur-The village of Panakura, in the poor ing the Shramadana camp, one of the Self-help is not always the righthilly district of Kegalle, provides a good Sarvodaya trainees has helped the mothers answer. In education, for example,example of the Movement's work. Simon organize a community kitchen and day- local financing can lead to such anJayawickrama had graduated from care center. Here young children are uneven distribution of qualifiedPanakura'sprimary school andwasdoing taught about health and hygiene, and teachers, books and equipmentwell in the secondary school two miles are vaccinated by a visiting governmentaway; then he had to drop out in the health worker (who received part of her as to intensify the inequities thetenth grade to help support his family. training from Sarvodaya). The school- country is trying to reduce. North-Through his former teacher and the local age children's group is responsible for a eastem Brazil and northem NigeriaBuddhist monk, he made contact with garden that helps to supply the community provide two cases in point. In boththe Movement; with the help of the local kitchen, and for keeping the community regions, low incomes partly explainSarvodayaworkersinnearbyAtulugama,center clean. The local Buddhist monkSimonbeganworkingamongstPanakura's took a four-month course on village why the wages and quality of81 families. After intermittent visits over development at the special Sarvodaya teachers fall below the nationala two-week period, a first Shramadana training school for monks. average; they also partly explainworkcamp was organized-to build a As well as extending its coverage, the the low enrollment rates in theseroad to the village. A second camp began Movement is improving the follow up to regions. If local economic andbuilding a community center-both proj- the initial Shramadana workcamp phase, social rogress lags well behindects chosen by the villagers themselves. to prevent backsliding. Although the s g gThe Sarvodaya Movement provided long-term effect of Sarvodaya's work the national average, financial andcement, reinforcing rods and skilled remains to be properly evaluated, most technical assistance from the cenlabor.For 15 weekends, 80 percent of the observers have been strongly impressed tral government will be crucial.villagers put in 6-8 hours of manual labor by the way it has involved people ina day. With the help of 100 young workers development. It has attracted widespreadfrom Sarvodaya groups in other villages, international support. Developing administrativethey established a community kitchen How much has all this cost? The strengthswhere everyone pooled and prepared Sarvodaya budget for 1979-80 was $2.3their food; took part in community medi- million, an average of less than $1,000 Institutional constraints are in manytation, singing, dancing and other cultural per village assisted. Voluntary labor and cases at least as serious a barrieractivities; and held two daily community otherpayments inkind contributed manymeetings (called "family gatherings") times that amount. Of the cash budget, to human development as shortwhereeveryone, young and old, had an some 80 percent came from international age of funds or lack of politicalopportunity to discuss their problems assistance (both private and official), 10 support. Effective administrationand ways of solving them. percent from Sri Lankan donations and usually requires more than theFollowing the workcamps, Simon and 10 percent from the sale of commodities efficient working of official bureau-10 others went to the Sarvodaya regional produced in Sarvodaya's training farmstrainir.g institute at Kegalle for a two- and schools. cracies; it depends on such factorsI as the availability of middle-level75
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t' 8 ~~~~ottoWorld Development Repo
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Oc 1980 by the International Bankfo
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ivThis report was prepared by a tea
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Text tables2.1 Summary of prospects
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DefinitionsCountry groups in the an
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illion people have barely enough fa
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in official aid and other capital a
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production and consumption; in- Tab
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measures can raise efficiency fairl
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adjustment; but the increases pro-
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dustrialized countries' GNP would T
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windfalls, some of their extra cont
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e done to increase the supplies Lat
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exchange-rate depreciation, by perc
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Table 3.2 World merchandise trade,
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Merchandise tradeAverage annual gro
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Percentage share of merchandise exp
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Percentage share of merchandise imp
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Destination of merchandise exports
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Destination of manufactured exports
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Current accountbalance before Inter
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Public and publicly guaranteed medi
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External public debtoutstanding and
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Amount1981a 1982a 1983a 1984a 1985a
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Average annualHypotheticalgrowth of
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PercentageCrude Crude Percentage Pe
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Percentage ofpopulation ofworking a
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Percentage of urban population Numb
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Life Infant Childexpectancy mortali
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PercentageDaily calorie supplyPopul
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Number Numberenrolled in enrolled i
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Percentage share of household incom
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Average index Tables 4 and 5. Growt
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28 (minerals, crude fertilizers and
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continues to grow after replacement
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posttax income and conceptually tic
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-~~~ S-~~~~~ sEuropean Office:66, a