A STRATEGY FOR BASIC SERVICES

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Title
A STRATEGY FOR BASIC SERVICES
extracted text
ASTRATEGY
FOR
BASIC SERVICES

SUMMARY
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The strategy is based in the village or the urban neighbourhood. The
villagers choose from amongst themselves people who could be “com­
munity workers”; the individual they regard as the best farmer, for
example, or the person they most trust for health care, or one they
naturally turn to for advice about raising their babies. These people are
given brief, simple specialized training with other workers chosen from
nearby villages or neighbourhoods. They return to their communities
to provide basic services and to help their neighbours learn new ways of
doing things: how to grow more and better foods, which local foods
would be more nutritious for small children, how to dig a well or la­
trine, why it is important that water be safe and used for keeping the
home clean, simple measures for preventing and treating diseases com­
mon in the area.

The workers are of the community and provide their neighbours
with services they want. Their neighbours, therefore, support them
and participate in the activities. Something like this is going on, here
and there, in many countries. In a few, this approach has evolved into a
strategy for social development, either countrywide or in specific
development zones.
Community workers alone could not function effectively or for long,
however. They must be part of a “system”—part of the network of
government services which have been augmented by auxiliaries, and
reoriented to support delivery to the periphery. They are the outer ring
of the national system for extending basic services into unserved or un­
derserved communities. They are, in fact, the final step by which
existing national services can be extended out to reach all those they are
intended to serve.

How community workers can be organized as part of government
services can be discerned in some of the common features of the suc­
cessful experiences already under way:

1

1) Community participation is the key to organizing and sustaining
these essential services in the rural village or poor urban neighbour­
hood. The people of the community are encouraged to participate
from the outset in identifying their needs, deciding priorities, plan­
ning the sequence of implementation and choosing from amongst
themselves those to receive training as community workers. This helps
take into account local traditions and establishes the responsibility of
the community for supporting its own services.
2) The priorities of the villagers or slum dwellers will suggest a
natural sequence for beginning different community services. They
should be planned in relation to each other and implemented as an
integrated whole as soon as possible. These essential services include
such activities as growing and storing more and better quality foods,
nutrition education, safe water supply and waste disposal, simplified
health care and health education, maternal and child health, family
planning, measures to meet the basic educational needs of the com­
munity, and the introduction of simple technologies to lighten the
daily tasks of women and girls. These various activities are mutually
supportive. Piecemeal, fragmented services do not work as effectively.
Often they are allowed to fall into disuse by villagers who do not fully
understand them or are not caught up in the enthusiasm of self­
development for their community.

3) The government, in undertaking the extension of essential ser­
vices to those not yet served, usually builds on the existing network of
services or on existing programmes in zones or development regions of
the country. These can be expanded, using the community worker
approach, based on community participation and support. Local situa­
tions will suggest opportunities for making the best beginnings.

4) Building on existing services will require a reorientation of the
government infrastructure to become supportive of the community ser­
vices. The existing network of services comes to provide the direction,
training, supervision, technical and logistical support, and referral ser­
vices for the village and community workers.

2

5) The network of regular government services will then need greater
numbers of auxiliaries to free professional personnel for supervisory,
training and other roles, and to support the community workers.
6) While community involvement from the outset is essential to suc­
cess, one stage obviously must precede this first step of implementa­
tion: commitment on the part of the national government to this strat­
egy. There may be resistance, for example, from those who believe that
services can only be delivered by fully trained professionals. If the
approach is to succeed, there must be political will and determination
to carry it through. Usually the programme can best be started in some
areas, but the final goal should be to adopt it as a massive approach
with the aim ultimately of reaching all those not yet served by essential
services.
While this approach draws upon experiences in a number of coun­
tries, there is no single model for developing basic services. Local cus­
toms and traditions must be taken into account in the entire process of
planning and development. Opportunities must be sought in local
situations. However, much can also be learned by exchange of informa­
tion about current and future experiences.

3

‘ ‘As tiie ultimate purpose of development is to pro­
vide increasing opportunities to all people for a better
life, it is essential
to expand and improve facili­
ties for education, health, nutrition, housing and
social welfare, and to safeguard the environment. ’ ’
Resolution of the General Assembly. 2626 (XXV) International Develop­
ment Strategy for the Second United Nations Development Decade, para 18,
adopted 24 October 1970.

The General Assembly:
“1. Urges the developing countries to incorporate
the Basic Services concept and approach into their
national development plans and strategies;....

3. Urges the international community to recog­
nize its responsibility for increased co-operative
action to promote social and economic development
through its support of Basic Services at the interna­
tional and the country programming level. ’ ’
Resolution adopted 21 December 1976

COMMUNITY HEALTH CELL
47/1, (First Floor)St. Marks Road
BANGALORE -560 001

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RATIONALE FOR A STRATEGY OF BASIC SERVICES
The concentration during the First Development Decade on economic growth as­
sumed that eventually all the people would benefit as the nation attained its indus­
trial and agricultural goals. In many countries this is not happening rapidly enough,
and the resultant disparities are a source of tension and conflict.

Originally it was thought that the existing pattern of governmental services would
be extended out to more and more people as economic progress allowed. Though
many governments have invested considerable resources in health and other services,
this has not occurred. Services based on older models of industrialized countries do
not spread far beyond the modern sector or scattered small areas where political pull
has succeeded in installing them. The industrialized countries are themselves finding
that, as salaries rise, it is necessary to use more lay workers in order to serve all the
people.
In the developing world as a whole, some three-quarters of the population is not
being effectively served. New generations are being born, growing up, and living out
their lives without minimal services or basic education, contributing much less than
they could to national development, and with some becoming a burden to them­
selves and to society.

Some countries, however, have evolved ways for meeting minimal needs by pro­
viding basic services. The World Health Organization and UNICEF studied various
experiences, focusing on approaches for meeting basic health needs. They observed
that common to most was a minimally trained lay person or persons, resident in the
village or community, whom they called the “primary health worker”. Such workers
are chosen by their neighbours, trained and retrained locally in specialized tasks and
simplified techniques, are supported technically by the health infrastructure and
work part-time in their previous occupation or are supported by the community. A
similar system can provide other essential services to meet basic needs.

Many simple measures that can improve conditions of life in the rural countryside
or poor urban areas are well known. Information about improving dwellings, which
local foods provide better nutrition and how to store them, the need for keeping the
household clean, why good sanitation is important to health, how to pipe water from
the mountainside or project wells, all these and many others are the very subjects of
basic education most needed by villagers or new urban dwellers. What is lacking is
the means for diffusing this information. Village or community workers not only pro­
vide minimal services but serve as the network for conveying this kind of basic know
ledge to the people.

5

Basic services may be criticized as offering second-rate services. This is mistaken.
Community workers are trained as technicians and become expert in precise tasks. In
mass immunization campaigns, for example, lay vaccinators became more expert at
giving a shot than supervisors who have wider professional training. As local people.
community workers make more approachable and knowledgeable home visitors than
outsiders. Community planning and supervision makes the system more responsive
to local needs than does distant bureaucratic control. Community workers offer a way
of beginning services which can be progressively upgraded as workers' skills are im­
proved by regular re-training and as resources grow.

This approach helps overcome the problem “where are the resources to come
from?" Basic services are labour intensive. They mobilize the resource that is abun­
dantly available but substantially neglected—human resources. A choice need not be
made between activities aimed at economic growth and measures for social develop­
ment. Both are necessary and mutually reinforcing. Involving rural villagers and
urban neighbours in organizing their own essential services can be the initiating
point for vitalizing the rural countryside or educating urban dwellers to become
skilled producers.
In the sequence of measures for stimulating people to become productive workers,
activities leading to their own improvement have a natural priority. When they find
that they can themselves take measures to improve their family and community living
conditions, a more modern attitude toward problem solving replaces the ages-old
fatalism that blocks progress. Upon this new attitude can be built improved agri­
cultural productivity and other measures benefiting national development. Once the
urban poor become involved in neighbourhood projects to improve their own lives,
their new energies and skills can be channeled into other constructive activities.

Many countries cannot soon extend expensive governmental services out to reach
all their people. The resources are just not there. Now, however, the experience of
areas where the people themselves are the principal resource for their own improve­
ment can be drawn upon. It is possible to make them a self-generating force for
economic growth and to do this with minimal start-up costs' and at long-term re­
current costs the community and nation will be able to afford.

6

ORGANIZING BASIC SERVICES
There is no single model for providing basic services. Numerous countries are using
some elements of this approach for meeting the basic needs of their people (for some
examples see pages 15-29). The approach can be made to work in different political or
social settings, provided the will is there to begin and to sustain the effort.
The undertaking should be thought of as a “process” by which—through ex­
perience and the exchange of experiences—the nation gradually finds the best way to
reduce rural and urban poverty by helping villagers and city dwellers take responsi­
bility for essential services at the local level. A programme of this nature and dimen­
sion can only be developed over a period of years, but should be carried out within a
time-frame that sets national and local goals.
There are places to begin, in rural development zones or other programmes already
under way. Existing services offer the organizational structure upon which to build.
Most government services at present consist of the national or ministerial level; the
supervisory level in the provinces or districts; and the present network of government
workers making direct contact with the people. To extend this core infrastructure so
that it effectively reaches the unserved or underserved communities, a fourth tier of
village or community workers is added. This requires reorienting the existing govern­
ment services to provide direction, training, supervision, technical and logistical sup­
port, and referral services for the new workers.

Starting programmes of basic services country-wide is usually too ambitious for the
initial stage. Various countries have begun in development zones or in a single re­
gion, as in the province of Puno in Peru or in the highlands of Chiapas in Mexico.
Experience in one region or zone then provides the basis for extending services to
other regions of the country, as is already being done in Mexico.

Initiation of services in an area previously unserved may come about quite natural­
ly. During the Sahel drought, for example, the health centre at Yako, in Upper
Volta, began treating children suffering from severe malnutrition. The mother or an
older sister was taught how to bring about the child’s recovery with a gruel made
from locally grown foods. His return to the village he had left only weeks before, on
the verge of death, had great impact. The mothers then became teachers of other
women of what they had learned about nutrition and local foods. To this were added
such measures as development of home gardens and nutrition surveillance. The
“Yako experience” is now being extended to other districts of Upper Volta and to
other countries in the region.
In planning basic services, the final objective should be to establish them on an

7

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integrated basis, so they will be mutually supportive. While it may be advantageous
or necessary to begin them sequentially, the intention should be to implement
essential services for each village or neighbourhood as soon as possible. An approach
that remains piecemeal, wastes resources and ill serves the intended recipients.

This is recognized in many programmes already under way, such as the Jamkhed
village project in India where health care is being developed along with measures for
improving agricultural production, increasing water supply, extending electricity for
irrigation pumps, constructing roads and buildings for schools and grain storage.
Health is considered pan of “total development”. Extensive community involve­
ment at the local level and use of the community’s own resources are stressed.
The “Salud Comunitaria" programme in Panama in addition to establishing
health posts, training local volunteer health workers and carrying out immunization
campaigns, supports cultivation of community gardens, and undertakes water supply
and latrine construction. The emphasis is on activities that create a healthy environ­
ment for the community.

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...

Community participation
While it is important to plan for basic services on an integrated basis, it will often
be advantageous to initiate services in a community sequentially, beginning with a
priority need established through discussion with the people. Water supply, for ex■ ample, may be a felt need in some places which will activate villagers to undertake
first this, then other measures for improving their community. This was the case in
Malawi, where villagers enlisted in piping pure water down from the mountainside
became motivated to begin activities of health, nutrition, sanitation and education.
They are now participating directly in over-all development programmes. A good
deal of experience confirms that joint work by representatives of government services
and community to meet a real need is one of the best ways to develop community
participation.

The people of the community should be involved from the outset in identifying
their needs, choosing the sequence for beginning village improvements and in imple­
menting them. This helps take into account local traditions, customs and agrarian
cycles of activity. Government workers at the next level above the community should
be able to be responsive to these initiatives. Development policy and support should
be flexible enough to follow leads in several acceptable fields.

Points of entry may be sought by some sort of survey of needs and aspirations,
preferably carried out by villagers trained for this purpose. A "community self­
survey” is being used in Indonesia to learn the needs and wants of the villagers. A

8

questionnaire is worked up and tried out on people from the community. Some
members of the test group are then selected to carry out the survey. After brief train­
ing, they survey the needs, existing resources and aspirations of their fellow villagers.
Community participation is often easy to begin but is also often neglected. In or­
ganizing “Project Compassion” in Quezon Province of the Philippines, for example,
the training of barrio leaders was received with such enthusiasm that, at their request,
the organizers conducted supplementary training involving all of the people in the
community. In another country, however, where local health promoters are being
trained to provide “simplified medicine” in remote communities, villagers are not
being effectively included in organizing or helping to carry out health activities.

Choosing the village workers
Community participation should also be invited in choosing the community
workers. The people of the community will place greater trust in their workers and
turn more naturally to them when they participate in choosing from amongst them­
selves those who are to receive training. Consultation is advisable between the com­
munity and the governmental services responsible for training and technical support.
Formal requirements, educational or other, must not be set so high as to exclude too
many community candidates. A village might have such workers as the village farm
adviser, a midwife, a basic health worker, a nutrition and child care adviser, and a
basic educator. When chosen by their neighbours, they can serve with more under­
standing than a better educated townsman who is unhappy with his rural assign­
ment.
Villagers in the Thiis region of Senegal, for example, select from amongst them­
selves the person to take a three-month course to become the volunteer pharmacist
and health worker for the community. In the Puno region of Peru the communities
are electing the young rural leaders who receive training to run the “initial educa­
tion” centres. In Niger, the choice by the villagers of their community health worker
is based on certain criteria: he or she must be a volunteer, live in the village and be
willing to undergo training. The “worker doctor” in China is chosen by fellow fac­
tory workers to become the health worker in their shop. The same is true with the
“barefoot doctor” in the commune.

Training the workers
The closer to their own community the village workers can be trained, the better.
However, it is obviously more convenient to train a number of workers simultaneous­
ly from a number of nearby villages—sometimes an existing facility may serve as a
training centre. Village workers in Botswana, for example, called “family welfare
educators”, are being trained at a rural training centre near the capital. They receive

9

eight weeks of classroom work and three weeks’ field experience in such subjects as:
nutrition, home economics, gardening and poultry raising, community development
and social problems.

The length of training may vary, depending on the subject and resources available.
‘‘Barefoot doctors” in China most often receive a three-month formal training in
either the county or commune hospital, divided between theoretical and practical
work. This is followed by a period of supervised, on-the-job experience. As many
have good educational backgrounds and all receive regular training and upgrading,
they become progressively more skilled; some becoming fully qualified doctors.
On the other hand, the courses in the Niger health programmes last only ten days
in the nearest dispensary, organized by the nurse in charge assisted by the chief nurse
of the district. The training of these village health workers covers general health con­
cepts, measures against epidemic diseases, health education, elementary health care,
emergencies and referrals. After this brief training, the village workers become the
frontline link between the people of the village and the national health service. Every
year, they attend a retraining course of ten days which gradually introduces new
topics, such as preparation of weaning foods and instruction about their use.
In addition to regular re-training each year, other ways can be found for regularly
upgrading the capabilities of the workers or augmenting their capacities for instruct­
ing their neighbours. In the nutrition programme in the Philippines, local leaders
receive new information each day through radio broadcasts in five local languages
providing educational and cultural programmes, project orientation, and language
instruction.

A way of integrating services at the community level might be to provide the
different members of the village or neighbourhood "team” with a basic training
before they go on to receive more specialized training in their specific tasks. This
is being done in Indonesia where it was found that, at first, training of local
leaders was too theoretical; now the training focuses on specific problems of the
villages from which local leaders come. They are receiving basic training to work
together as an “integrated team” to lead the villages in solving problems of nutri­
tion, education, environmental sanitation, family planning, and non-formal
education for school leavers.
This may be more elaborate training than some countries can undertake during the
initial phase of organizing basic services. Where training of village or community
workers must at first be brief, however, it can be repeated and upgraded in courses
given every year and through on-the-job supervision and instruction.

10

Simplified techniques and technology
Much modern technology and many techniques are inappropriate or irrelevant to
the immediate needs of villages or shanty-towns. Intermediate technologies, devel­
oped out of local experience and making use of local materials, are better suited to
the immediate tasks of community workers. These might be thought of as "next
step" techniques and technology—starting out from where the villagers are right
now, rather than trying to impose modern methods and equipment upon them.
In the area of health, the World Health Organization is circulating information
about simplified medical techniques suited for basic health workers trained for speci­
fic tasks. UNICEF is collaborating with other UN agencies in developing village-level
technologies, such as the simple hand-operated milling and husking machines that
have been made available to villagers in Senegal to lighten the workload of women.
Other measures being tried include:
- improving traditional methods of crop storage to reduce losses in quality and
quantity, which sometimes run as high as 30%;
- manually operated cereal and legume grinders and millet threshers;
- improving cooking arrangements to reduce fuel consumption and dangers to
children;
- using sunshine for drying crops, treating water, and cooking food;
- manually operated oil extraction presses to enable communities to extract oil
from their locally produced oil seeds;
- using wind and water power for pumping water, grinding cereals and legumes
and for small-scale production of electricity.

Community support
In addition to helping plan their community’s activities and selecting their fellows
to be trained as workers, the villagers or urban neighbours participate in the initial
costs and in supporting local costs of basic services on a continuing basis. It is an es­
sential feature of the system of basic services to keep local costs to a minimum. In
some cases, village councils or individuals appointed for the purpose may manage the
local services.

For the capital costs, community support may take the form of providing a build­
ing or contributing labour and materials for construction. The rural maternity at
Touba Tou, in Senegal, was built by the villagers as a community effort. The coTnmunity leader urged them to make the centre as home-like as possible for the new
mothers, so the straw-thatched, mud-walled huts are copies of the village homes, ex­
cept for concrete floors installed for easy cleaning.
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OwAQ

COMMUNiiY n.ALTH CLLL
47/1, (First Floor) St. Marks noacj

BANGALQrtE - 560 OWi

Community support towards running costs may be provided by the local adminis­
trative unit, that is from taxation; by a co-operative; from health insurance pay­
ments; by fees or gifts for services, and by payments for medicines. Community
workers may contribute their part-time services on a voluntary basis while they con­
tinue to support themselves from their regular source of income. Alternatively, they
may be paid directly or with individual gifts in return for services.

The rural maternities in Senegal are supported by fees—if the new mother’s family
can afford to pay cash, a week’s stay costs 350 Senegalese francs (JUS1.50). Fifty
francs goes for maintenance of the maternity centre; the remainder is accumulated
and every six months divided amongst the village birth attendants who run the
centre. For those who cannot pay in cash, the family brings some eggs, a chicken or
two, sometimes a leg of lamb.
Community support of basic services can bring them within recurring costs that the
nation will be able to afford. A cost-benefit analysis would probably show that the in­
vestment is repaid many times over in a growth of the national economy as the people
become motivated to participate more effectively in rural and national development,
not to mention the direct contribution of the services to raising the level of living.

Auxiliaries - the link to the next level
Community workers need a good link to the national infrastructure, to be able to
refer cases they cannot deal with, and to receive technical information, logistical sup­
port. and supervision. Many systems provide for a visit to the village every week or
two weeks. Such a programme can only be fulfilled by auxiliary workers, with a much
less frequent visit by professional staff.
Most countries are now using auxiliaries—auxiliary nurse-midwives, sanitarians,
health visitors, community development workers, promoters, anirnateurs, monitors
and others with local denominations. The basic services system means using them, as
well as other parts of the present infrastructure, in a different way. They would not
make the primary contact with the client for the delivery of services, hence serving
only a small proponion of those in need. Instead, auxiliaries should become pan of
the support system for the community workers—guiding and helping them, bringing
them supplies, dealing with cases and problems that the community worker refers
upward because he is not qualified to handle them.

In addition, more auxiliaries will usually be needed. With the great expansion
of coverage made possible by the basic services programme, the workload of sup­
port services and referrals will be greater than the primary contacts they han­
dled previously.

12

Referral/Supervisory levels
The next level in the system is the support echelon or the first referral level. It may
be the health centre in a larger village, or the provincial or district office of the de­
partment of agriculture, of public works, of education, etc., situated in the district
town. It is directed by fully trained professionals, and provides the base for the auxil­
iaries who are travelling out for regular visits to the community workers.
Supplies reach the village workers through this point. Community workers, trained
in simplified techniques to provide basic medical treatment, refer more serious ill­
nesses or injuries on to the health centre or major clinic operating at this next level. A
major function of this level will be the training of community workers, technical
guidance, direction and the supervision of their performance. The province or district
provides an important level of co-ordination among the services of the different min­
istries concerned. The needs of different areas in such fields as drinking water, access
roads, expansion of production, health and educational services, are so concrete that
it is easy for those responsible for each of the sectors to see the greater return to be
obtained by making their services mutually supporting. The interest and support of
the population can be fostered more effectively, and the educational and develop­
mental messages going out to them will not be contradictory.

There may be several referral and supervisory levels between the village and the
national government, depending on the administrative structure of the country and
the service concerned. A federation has an additional state level. Health and educa­
tional services will usually have more levels than agriculture. However, similar prin­
ciples apply.
Success in developing village services will generate increased workloads at the re­
ferral and supervisory levels. Some expansion of professional staff will be necessary,
along with a major expansion of auxiliary staff. Personnel already in position will
need in-service training to reorient them to their changed functions. In order to bring
referral services within reasonable distance of communities, it will usually be neces­
sary to open some new centres or offices of the district type.

A common weakness is to give too little attention to the reorientation and training
of staff at these intermediate levels, including in an appropriate way the senior ad­
ministrators. Without a change of outlook and work plan of the supporting staff, the
community-level workers will be under-trained, under-supported, and under-supervised. Good reorientation usually includes exposure to working systems at field level,
and work in groups similar to the teams of different professions and levels that need
to work together. It is frequently said that the necessary reorientation of the sup­
porting services must occur first in the minds of the government officials.

13

National Level
Basic services should be integrated at the village or community level, and at the
district level, but support for this has to come from the national level. While the local
level should contribute substantially to the cost of services with visible benefits, the
centre has to provide the cost of training, direction and supervision, and much of the
cost of equipment and supplies that come from outside the area.
The main responsibilities at the national level will be to provide long-term plan­
ning of basic services integrated with development, to give impetus to the implemen­
tation of agreed policy, to provide budgetary support, to ensure co-ordination, and
arrange for some continuing monitoring or evaluation with the objective of achieving
maximum effectiveness.
The concept of basic services involves a number of ministries and cuts across
conventional departmental or sectorial planning and budgeting procedures.
Common planning can be accomplished through an interministerial commi"f|‘
by the social division of the planning commission in contact with the planning cells
of the different ministries, or by the office of the president or prime minister.
As can be seen in the experiences which follow, the national plan can provide for a
programme of basic services either country-wide or starting in one region, then
extending that experience.

The Young Child
In developing basic services, special attention must be given to the needs of the
young child. The first five years of life are the formative vears. Whether an individual
survives the first few years and how, determines whether he or she will grow up into
an energetic, productive adult. Malnutrition can make mild childhood diseases fatal.
Prolonged poor nutrition can leave the child retarded or lacking in curiosity, energy
and capacity of learning. Lack of calories, vitamins and minerals, prevent the child
from growing fully or leave him or her blind. Many of the diseases of childhood can
leave the individual permanently crippled or ill.
On the other hand, improved conditions of family and community life help over­
come these many dangers of childhood. Improved midwifery, minimal preventive
health measures, improved water supply and sanitation, cleanliness in the home,
basic mother and child health care, knowledge on the part of the parents of family
planning, better nutrition, campaigns for immunization and distribution of vitamin
A to prevent blindness—all can be carried out by basic village workers to help the
small child grow to his full potential.

14

THREE EXPERIENCES
Planning zones
Recent experience in Indonesia suggests how basic services can be planned and im­
plemented as pan of economic development in planning zones. The regional plan­
ning process in that country aims at overcoming inequalities in the rate of develop­
ment between different regions and different segments of the population. The Na­
tional Planning Board created 10 regional zones with four urban growth centres.
Within these regions, areas were selected as development zones. The Govern­
ment’s goal is to achieve basic services in the rural villages and urban neighbourhoods
of these zones.
The Government set about through the National Planning Board to create plan­
ning boards in each region and city planning units in most of the urban centres. The
capacity of these sub-national planning units is being built up by involving the new
regional and urban planners directly in formulating the plans for the selected de­
velopment zones. From the outset, the regional planners in addition to a six-week
training course have been involved in collecting data, conducting surveys and an­
alyzing needs, helping to formulate zonal plans, and implementing these in the field
on an experimental basis to assess their suitability for wider adaptation.
The basic services are being developed in a “converging” way—that is, those that
already existed are being pulled together and others established to fill in the gaps so
that minimum services will be delivered in a co-ordinated manner to all families in
each development zone. These include: basic health services, water supply and sani­
tation, nutrition and growing of more nutritious foods locally, schools and non-formal education.
How this is being done can be seen in one of the first development zones of the
new regional planning programme, the kabupatan of Indramayu on the nonh coast
of West Java. This area, with more than a million people living in 184 villages, suf­
fered from recurrent food shortages caused by alternating floods and drought. The
principal crop was rice. Under-nutrition and malnutrition were serious, especially
amongst infants and small children. Infant mortality was high; life expectancy low,
the birth rate high, health facilities remote and underused, most households were
getting water from unsafe sources, waste disposal was unsanitary, and a third of the
population illiterate. A large part of the work force was composed of landless farmers,
with severe unemployment and underemployment; many went to Jakarta in search of
work as seasonal labourers.

Development of the infrastructure within the area was unbalanced. While there

15

were government services, they were fragmented, concentrated in some areas and not
reaching all the people of the area. The purpose of planning was to pull these existing
services together, to augment and extend them more uniformly throughout the
countryside. The numbers of personnel were not sufficient to maintain contact with
the communities, and most activities were not co-ordinated in a way that would con­
tribute to development. Community development activities, where they existed,
relied chiefly on depanmental field workers.

The Government set about to change these conditions through the regional plan­
ning mechanism. Until the regional planning board was sufficiently developed to
function on its own, the National Planning Board provided a multi-sectoral team
from the various ministries to give leadership in preparing the plan for the develop­
ment zone. The regional planning trainees, after initial formal training, participated
in data collection, survey of needs, assessment, and preparation of the plan. The
planning process involved interaction between ongoing activities in the field, and the
survey and analysis upon which the plan was formulated. Seminars and workshops for
regional planners from different zones provided opportunities to exchange ideas and
experiences between the various regions of the country, which differ both in needs
and in possibilities for social development. In addition, regional planning personnel
from Indonesia visited Malaysia and the Philippines.

In Indonesia, the people have a tradition of mutual help—gotong royong—so
that community participation is natural to them. Previously, community develop­
ment had largely concentrated on strengthening the professional capacity of depart­
mental field workers and supervisors. Village leaders were receiving some training,
but during the planning process their training was assessed as too theoretical and
classroom-oriented. Both the methods and content of training were revamped so as to
focus on the specific development activities designed to solve problems similar to
those in their own villages and to enable various village leaders to act as “volunteer
community workers” in the way described in the preceding section. Most of the
training now takes place in the field. This change in the content and style of training
applies to the community development programme as a whole.
Greater numbers of departmental field workers (auxiliaries) are being trained to
support the activities of the village leaders and to serve as the link between the com­
munities and the government services provided by various departments. The auxil­
iaries and community leaders, after receiving basic training together, now work as
integrated teams, catalyzing community action in planning and implementing vil­
lage projects. These include: rural drinking water supply and sanitation.; nutrition
and local food production; basic health services; community school projects; nonformal education and pre-vocational training of young people. Developmental activ­
ities include, water for irrigation; diversification of agricultural production; soil con-

16

servation; marketing and small-holders’ credit facilities; environmental sanitation;
and human resources capability development.

Most of these activities rely heavily on community support in the form of money,
material and volunteer labour. The Government now provides an annual subsidy
directly to each village for capital investment aimed at physical and economic de­
velopment of the community. The village leaders have been trained in various aspects
of community management and development.

Countrywide
Tanzania is an example of a country in which the Government is committed to a
policy of establishing minimal essential services for all the people of the nation as
soon as possible. The Arusha Declaration placed the emphasis in development on
“the people and their hard work” and stated that “this is the meaning of selfreliance”. As more than 90 per cent of the population lives in the countryside, the
stress is on human development in rural areas.

As much of the population was scattered, the Government proceeded on a course
of “villagisation”—to bring people together into larger settlements so that basic ser­
vices could be developed more effectively. This is being done through either Ujarnaa
villages or other development villages. Top priority is given to provision of water,
basic health services, and universal free primary education. Goals have been set: basic
health services to all the population by 1980; a good accessible water source for each
village by 1980; universal free primary education by 1977.
The principle of self-reliance led to decentralization, with community involvement
in planning at the start of each project. Mass mobilization is used to raise the con­
sciousness of the people to make them responsible for meeting their own needs. The
guidelines of the TANU party state that it is not the leaders and a few experts who
decide the plan and then urge the people to implement it, but the leaders and ex­
perts must implement plans agreed upon by the people themselves. Responsibility
for their own development and much of the power to marshall resources towards that
end have been devolved upon Village Councils..
The party organization extends down to the village level. At each administrative
level—village, district, region and nation—planning committees include elected re­
presentatives of the people as well as departmental experts. The people of the com­
munity are involved not only in planning but in implementing projects.

In the newly settled villages—consisting of 100 to 500 families—the people of the
community are being helped to create their own basic services. Specially trained de-

17

velopment workers assist the villagers, but the villagers choose from amongst them­
selves those who are to become basic health workers, teachers, the village agriculture
leaders, water pump attendants or day-care centre leaders. All become “village
actioh leaders”.
Attitudes of mutual respect, co-operation and equality are fostered in the villages,
and emphasis is placed on local contributions to developing the village services.
For example, village health posts and dispensaries are constructed by the villagers
with the Government contributing materials, equipment and services which
cannot be supplied locally. Sometimes an existing building is used. The villagers
also help construct the water supply system and build their own sanitation facil­
ities. Simple tools and methods are devised and local production encouraged for
meeting local needs.

The way village medical helpers are trained and carry on their activities with the
support of the community suggests how village workers are being developed to help
the villagers provide their own basic services. The training is a three to six month
practical course at a health centre or district hospital. While the Government would
prefer that those chosen have seven years primary education, this qualification is re­
laxed in training—as local medical helpers—healers, medicine men, traditional birth
attendants or herbalists.

A village medical helper can treat minor illnesses, dispense simple medicines from
the local dispensary and provide emergency medical treatment for injuries, but he
refers more serious cases to a rural health centre. Health education is carried on by in­
forming the people of the village about such matters as nutrition, hygiene and sani­
tation. This is an important part of the work of mobile health teams, as well as the
local medical helpers. The village medical helper is not paid; his service is regarded as
his contribution to the work of developing the village.

Above the local dispensaries, rural health centres and mobile health teams, are
district hospitals, under the supervision of the District Medical Officer. At the next
level, there are regional hospitals, under the Regional Medical Officer. These activi­
ties are co-ordinated by Regional and District Development Directors and, at the na­
tional level, the Ministry of Health co-ordinates with the Ministry of Agriculture and
Cooperatives and the Ministry of Labour and Social Welfare. Nationwide health cam­
paigns are carried out, providing information through radio, magazines, booklets,
posters, and newspapers about specific diseases and preventive health measures.
Similar approaches are being used to provide water, education, improved nutrition
and agriculture at the village level. In all of these the element of self-help is of pri­
mary importance.

18

Village teachers are being trained and retrained in formal and non-formal educa­
tion techniques. The philosophy of “Education for Self-Reliance” calls for Basic
Education for adults as well as children, to give them the role of agents of change in
their community. It includes learning more suitable methods of farming as well as
other aspects of rural development.
Basic Education is regarded as an essential component of other basic services and
helps to co-ordinate them at the village level. Nutrition education, for example, is
incorporated in mother-child health services, schools, day-care centres and in agri­
cultural instruction. The co-ordination of the various services results in their being
mutually supportive.so that a heightened understanding on the part of the people
strengthens the basic services in the villages.

Starting in one or a few regions
The project under way in the department of Chuquisaca, in southern Bolivia, is an
example of basic social services being developed in co-ordination with rural develop­
ment in a region to provide experience for replication later throughout the rest of the
country. The Government aims at bringing the campesinos (who make up two-thirds
of the nation's population) into national development. In 1972, it chose Chuquisaca
and another province to carry out the first regional economic and social development
programme. Among the reasons for choosing this region:
- the existence of Provincial Committees for Development (created originally in
1938 toadminister oil revenues);
- existence of an infrastructure of social services which, though inadequately de­
veloped, offered a basis for implementing the plan of action; and
- the variety of local situations were ideal for an experimental project, from which
experience gained could be adapted to other regions of the country.
While the mortality rate was high, the ten major causes of disease were susceptible
to control by preventive measures. Malnutrition was high among children under five;
food consumption per capita was estimated at only 73.2 per cent of daily require­
ments; 82.4 per cent of the population had no safe drinking water supply and 92.5
per cent no sewage disposal system. Of 235,200 young people of school age, only
85,857 were enrolled in school. Unemployment, particularly affecting youth, was
approximately 25 per cent. Though agriculture was the principal economic activity
in the region, 45 percent of land suitable for farming remained unused.

The area has oil reserves but per capita income remained at approximately $110 per
year. It was recognized that revenues from oil would flow into the region for only a
limited number of years, so they must be invested in a way that would bring long­
term development. The Provincial Development Committee had attained a high
level of managerial capacity and offered a decentralized provincial government

19

authority, with its own financial resources, through which to carry out economic and
social innovations. The aim was to improve living conditions at the same time that
the people in marginal rural areas were being brought into development. A division
of Social Development was set up to help the Committee deploy—in a mutually sup­
porting way—the activities of departments dealing with works (for access roads and
water), agriculture and animal husbandry, education, health, etc. At the provincial
level, where the departments are in touch with the specific local needs of communi­
ties, practical co-ordination has been achieved more easily than at more remote levels.
Typical villages were selected in which to begin activities. Using the local govern­
ment structure, the people of the communities were brought into the development
process. The realities of the villages and the needs and wants of the people were the
basis for agreement on how to proceed. Initial activities concentrated on building
needed structures, for health posts or schools. The people contributed labour and
local materials while learning basic skills. This led to community involvement in
various activities aimed at creating the basic infrastructures for economic as well as
social development.

These activities include construction of access roads, increased production of fruits
and vegetables through small-scale irrigation, community crop storage, sheep raising,
both production and consumer co-operatives, and handicraft workshops. Young
people are being trained in construction work or in improved techniques for intro­
ducing new crops. Efforts are under way to improve rural housing, and community
participation is being stimulated to provide health services, water supply and envi­
ronmental sanitation, and education.
The inter-sectoral approach is being furthered at the community level by using the
“nuclear school" as a community centre. (Bolivia, along with some other Latin
American countries, has been developing for thirty years the “nuclear school"
system, which has a central school with outlying satellite schools grouped around it
and supported by it.) Villagers of all ages are being trained to participate actively in
development tasks. Basic instruction is given in such subjects as health education,
education to improve the rural economy, and home economics. To aid in construc­
tion of such facilities as health posts, schools and access roads, short courses are given
in masonry and carpentry. Other courses explain the objectives of the rural economic
and social programme to school teachers, and they are being motivated to participate
actively as agents of change in their communities. Each community is choosing its
own priorities and setting the sequence for implementation. While in the preliminary
stage organization at the community level tended to be weak, a constant process of
consultation with the people aims at reformulating activities so as to gain community
support. The strategy of rural economic and social development being evolved in this
region of Bolivia has now been incorporated into the five-year development plan
for 1976-1980.

20

'"

-

BRIEF EXAMPLES
The following, examples illustrate the many different experiences that can be
drawn upon by countries wishing to extend basic services. Not all present initiatives
are included. Most of the examples described have not reached the st rge of compre­
hensive basic services, but are still developing:
Bangladesh. A rural health insurance scheme centered.in the thana of Savar (popu­
lation 200,000) illustrates community involvement and support, the use of village­
level workers, and growth from basic health services into agricultural and home eco­
nomics extension at the village level. Families subscribe the equivalent of US 25 cents
per month for out-patient treatment, vaccinations and family planning services, and
receive hospital treatment at a reduced charge. There is a hospital, 11 sub-centres,
and part-time health workers in each village. Some of the latter have been recruited
from among senior students in the schools.
The health services scheme is seen as part of general development, and it has come
to provide an extension system giving information and demonstrations about better
agricultural practices, local crafts, family gardens, home improvements, etc.1
Botswana. Offers an example of village level auxiliary workers called "family wel­
fare educators" who are promoting child care, family health, family planning, and
nutrition and home economics. Candidates for training are primary school leavers, at
least 20 years old, who live in and have the approval of the community they will go
back to serve. Training is given for two months at a rural training centre with practice
areas. Upon completion of training they are employed by District Councils. They re­
ceive a supervisory visit at least once a month, usually by a nurse. 2

Brazil. The work donf by the Brazilian Association of Credit and Rural Assistance
(ABCAR) and its affiliated state associations, offers an example of an unusual starting
point for what grew, for practical reasons, into rather comprehensive services. From
its primary concern, when founded in 1948, with small agricultural credit and exten­
sion, ABCAR has added water supply and health services, better food and nutrition,
education, and rural youth activities. This has come about with involvement of the
rural population and co-ordinated support of government agencies in these fields.
ABCAR’s local offices are at the level of local government (municipia), and the staff
1.

Zafrullah Chowdhury, The mother and child in Bangladesh - a view from the People’s
Health Centre, Les Carnets de 1’enfance, No. 33, January-March 1976. UNICEF, Geneva,
pp.68-77.

2. Marit Kromberg et N.N. Mashalaba, La formation des monitrices en mieux-etre familial au
Botswana. Les Carnets de 1’enfance, No. 33, January-March 1976. UNICEF. Geneva,
pp. 97-108.

<7/4

De t' /Ao

coMMUNnv HERLTH CEtL

always includes a woman trained as a teacher or in home economics, social work, or
nutrition. At the level below, community leaders are trained through short courses
and serve as volunteers, working with local groups and individuals.
Central African Republic. In Basse-Kotto (population 110.000) a number of com­
munes are developing basic services with support coming in the first place from the
national community development organization, and based on rural community de­
velopment centres. (An economic base is provided by the development of fish ponds
and market gardening.)
Health services have been drawn in, and new health centres and health points es­
tablished, substantially staffed by para-medical personnel. MCH services and immu­
nizations are being emphasized. Teachers are being given refresher training as part of
a reform of education designed to make it relevant to village life.

Colombia. A scheme forextending services to some shanty-towns around Cartagena
is taking as its initial activities day care, health education and preventive health ser­
vices. literacy training and family life education, recreation and sports. The services
are based on neighbourhood development centres. Low-cost loans are given for pur­
chase of tools and materials for house improvement and for job training for young
persons.
Costa Rica. Primary health care delivery has been extended into the unserved areas
of the nonh of the country since 1972. Services included vaccinations, improvement
of environmental sanitation, family planning, school and family gardens. New
health centres have been opened. The number of auxiliary health workers has been
expanded and a new category of local community volunteers has been established.
Because this system is regarded as working successfully, the government has decided
to use the infrastructure to extend other basic services to the village level. 5

Egypt. Experience in providing urban basic services is being gained in projects
under way in Boulak Eddakrour in the Giza Governorate, Shubra El-Kheima on the
outskirts of Cairo, and Darb El-Ahmar in the inner city of Cairo. Citizen participa­
tion is being encouraged through citizen committees concerned with' meeting specific
physical needs of the communities. In the early stages, citizens groups dealing with
water and sewerage, for example, were having greater success than those concerned
with women’s activities and youth affairs. The active participation of citizens com­
mittees in programme implementation has been an important stimulus to the
Government in developing a national policy for meeting the needs of the urban
poor.3
3. William Vargas Gonzales, Programas de nutricion aplicada en zonas rurales de Costa Rica,
Les Carnets de 1'enfance, No, 35, July-September 1976. UNICEF, Geneva, pp.80-91.

22

India. Andhra Pradesh, Hyderabad. Urban community development, under way
for eight years, now reaches 60,000 out of 300,000 slum dwellers with a wide variety
of improvement programmes—from primary health care and pre-school programmes
to house construction and environmental upgrading. A small experienced staff works
mainly with groups of slum dwellers who organize and act on their own behalf. The
staff is committed to the principle of linking physical improvement of the slums with
human services. An extension is under consideration to provide a broad spectrum of
basic services to all children in the 0-6 age group.

"Indo-Dutch" Project. Originally, a project aimed at delivery of integrated health
services only, it is gradually moving towards community participation and inclusion
of other services, notably pre-school education and nutrition (with emphasis on the
use of local foods for weaning).

“Crisis”. A voluntary organization supports this project, so called because it starts
in crisis situations, usually where simple house construction is the first need after
floods or other disasters. With trained volunteers the project extends community selfhelp with very little material aid to other areas of concern to the villagers.
Gujerat, Vasna, Ahmedabad resettlement project. The Ahmedabad Study Action
Group (ASAG) has built a colony for 2,250 families whose slum colonies were de­
stroyed by floods. These were the significant aspects:
a) the successful collaboration of municipal, state, centre, international agen­
cies, and local voluntary organizations;
b) the involvement of the slum dwellers from the outset to make this a total de­
velopment project rather than simply a resettlement one;
c) the fact that the people are buying their own houses over a period of 18 years at
$2.50 per month.

Haryana, Narangwal. A well established model of primary health care services in a
small area is administered by the All India Institute of Medical Sciences, as a pilot
area for primary health care training. The AIIMS advocates the use of village level
workers in primary health care, and plans to go beyond the field of health as soon as
possible. It also plans to extend the pilot area to cover an entire district.
Maharashtra, jamkhed in Ahmednagar District. An experiment in primary health
care services was started in 1970 in a rural area of 30 villages (40,000 population). It
trained female village health workers and brought the Ayurvedic doctors and tra­
ditional midwives and healers into the system. Auxiliary workers from the next
echelon visit each village once a week. Two doctors guide the services and man the
health centre atjamkhed.

23

Through close contact with the people, the village health workers found that their
priorities were not health services but an increase of agricultural and food production,
access roads, electricity and the provision of irrigation and drinking water and
housing. The project responded to these needs in various ways within its means, e.g.
by renting cultivating machines, deepening wells, providing better seeds, etc.
The community participates in decisions, provides land and buildings, gives food­
stuffs for supplementary feeding, builds roads, mobilises the population for vac­
cination, etc. 45

Kasa development block. With the support of the paediatrics department of the
Institute of Child Health, Grant Medical College, Bombay, services are being de­
veloped in 60 villages served by the Kasa health centre, which constitute a tribal
development block. To the professional and auxiliary staff of the health centre has
been added a further level of link workers with the villages, comprising 28 “parttime social workers”. They are recruited from the villages and serve two villages or
about 2,000 people each, receiving an honorarium of Rs. 80 or USS 9 per month.
They deal with basic child care including monthly weighing; nutrition education and
distribution of nutrition supplements made from local foods to the seriously under­
nourished young children; immunization; family planning; and referral of those
needing the attention of the health centre. They are trained to detect and give par­
ticular attention to those “at risk” among the under-sixes and married women. The
PTSWs meet with the villagers and their leaders and inform them of the nutritional
and immunization status of their children. They also inform them about those who
are "at risk” and the social problems involved. Local government at the village,
block and district level is beginning to share the cost of the PTSWs. ’
Mau. In pan of the Segou region there is a 15-year plan for expanding rice
production with bilateral assistance. In 1973, a social service component was added,
including functional literacy; MCH and health protection; projects for lightening
women’s work (through wells, mills for grinding cereal, hand carts); and the
participation of youth in development (provision of land for them to work and
workshops for rural crafts).
A cell has been set up in the National Directorate of the Plan to work in close
liaison with the different ministries providing support services at the local level.
4. Alternative Approaches to meeting basic health needs in developing countries. WHO,
Geneva, 1975, pp.70-77.

5. P.M. Shah, Community participation and nutrition - The Kasa project in India, Les Carnets de 1’enfance, No. 35. July-September 1976. UNICEF, Geneva, pp.53-71.

24

Women’s clubs are an important channel of community participation. This cell
is co-ordinating efforts to extend this approach to other regions with different
economic basis.

Mexico. In the highlands of Chiapas, comprehensive services at the village level are
being extended to the predominantly Indian population, until now outside the
mainstream of national development. This programme has the strong support of the
Governor, who seeks a co-ordinated deployment of the departmental services. When
the programme began in 1970 one of the first steps was the establishment of a net­
work of radio communications between the larger villages and the operational centre
in the chief town in the highlands. This greatly increased the possibilities for local
participation. Activities were then undertaken to increase income in the area and to
deliver health and education services.
Auxiliaries are used in extension (rural promoters) and health (auxiliary nurses).
Auxiliary nurses with three months training are provided with food and lodging by
the community. School teachers receive refresher training as part of a programme to
use schools also as centres for non-formal education.

At the village level, community leaders are being trained and have become a source
for many programme initiatives. Lay midwives have been drawn into the health
system; women’s and youth clubs provide additional links with the community.
An Indian community radio broadcasts in the four Indian languages, and includes
information about agriculture and home economics, family planning, nutrition
and local food production, water supply, health, education, youth clubs and
women’s clubs.
*
The programme is now being extended to backward areas in a number of other states.

Niger. In the department of Maradi, a primary health care delivery system has been
considerably extended since 1966, with the joint support of the ministries of health,
animation rurale, and education. The starting point for any locality is a discussion
between the inhabitants and high-level representatives from these ministries and the
political party, held under the chairmanship of the prefect or the sub-prefect.

Health services are extended by training of village first-aid health workers who are
provided with a “village pharmacy” containing simple and “safe” medicines useful
against the region’s most common illnesses. The first-aid and health workers are
volunteers, working pan-time and receiving some food from the community. They
attend a ten-day refresher course each year at the nearest health centre. Village mid­
wives are also receiving training and refresher training. A village management com­
mittee oversees the work of the health team and the pharmacy. More women exten-

25

sion workers (animatrices) are being trained. Help is being given for family food pro­
duction. The programme is being extended to other departments. 6

Pakistan. A “country health planning exercise” undertaken with WHO’s assis­
tance during 1975, is leading to application of the primary health care approach to
different degrees in various provinces. In the Northern areas under federal adminis­
tration, there are already some 1,600 "health guards". In villages of the North West
Frontier Province, as part of an integrated rural development programme, a modest
start has been made in the delivery of eleptentary health services by some of the reli­
gious leaders. The province of Punjab has begun training medical assistants. Balu­
chistan has started training health auxiliaries. The province of Sind has pioneered
polyimmunization of children; a service which will be extended by all provinces.
The provinces are also giving technical and material support to localities for the ex­
tension of a safe water supply, according to the widely different hydrogeological con­
ditions. In the field of education, the Government has set a policy objective of de­
livering basic education to the outlying villages.7
Panama. Earlier experiences with health and water programmes led to two
different organizational patterns for extension of basic services, in different areas
of the country.
The Salud Comunitaria programme aims at promoting and protecting all aspects
of community health. Its components include: mother and child health care, adult
medical services, health education, and nutrition measures. An extensive water sup­
ply and sanitation programme was carried out during an earlier phase. As a first step,
the Government promotes community organization. Local health committees are
formed, and the people participate actively in nutritional and agricultural measures.
The Government provides technical advice on agriculture as well as in health matters.
The health committees art; in charge of distributing the food harvested for local use;
they sell the surplus produce and administer the revenues to provide for the health
needs of the community. •
The other organizational pattern has led to a programme of integrated basic
services in the nine least developed municipios of the country. The administrative
unit is the electoral district and the elected representatives from these districts in the
Alternative approaches, op. cit., pp. 78-83.
K. Zaki Hasan, The rural Health Guards in the northern areas of Pakistan, Les Carnets de
1'enfance, No. 33, 1976, pp.78-87.
8. Cutberto Parillon Delgado, In production alimentaria a traves de huertos comunitarios en
Panama, Les Carnets de 1'enfance, No. 35. pp.92-99-

6.
7.

26

Assembly assist in directing the programmes. Teachers also serve as volunteer com­
munity workers, as well as being concerned with agriculture and rural crafts’.
Peru. In the province of Puno, a programme for delivery of services has a number
of interesting features—a provincial development planning committee; the revival of
traditional Indian community ownership and responsibility; and the strategic im­
portance given the young child.
Economic development is based on revival of silver mining and improvement of
pastoral industry, crafts and local family food production. There is a policy of com­
munal and '‘social” property. Part of the revenue from social property must go to
support community services.

The extension of services has begun with “education initial”, a noh-formal pro­
gramme for pre-school children. The decision to start services for young children was
based on modern knowledge of child development and the belief that this would be
the best way to overcome fatalism so as to improve initiative and enterprise in the
Indian communities.
There has been a good response from the communities and parents. They choose
the person (“promoter”) who will be responsible for the pre-school programme in
their locality, and support him. He receives short-term training and refresher courses
every year. In 1976, the programme has been adopted by 122 communities.

The next step is to improve formal schooling as these children reach the school­
entering age. Health services are being extended and 50 health promoters have
been trained. Radio programmes have been started in the Aymara and Quechua
languages.

Philippines. “Project Compassion”, launched in mid-1975, aims at intregrating
four programmes reaching into the community - the green revolution, the Phil­
ippines Nutrition Programme, and population and environmental programmes
(clean water and waste disposal). These are to be linked into one delivery system
reaching one million of the high-risk households in ten selected provinces, based on a
combination of government and private agency work.
The Philippines Nutrition Programme is already reaching into communities with a
common approach of all government and private agencies concerned. At the centre is
a National Nutrition Council, including six cabinet ministers and three representa­
tives of private agencies. There are nutrition committees at the regional, provincial,
municipal and barangay levels.

27

The municipality is the focal point; in 1976 there were 1,500 municipal nutrition
programmes throughout the country. The final link between the nutrition agencies
and committees and the families is provided by the barangay network. Under the
guidance oi^purok (zone) leader, who is called a "teacher-co-ordinator”, volunteer
community workers are each responsible for watching the nutrition of twenty fami­
lies. (This is an adaptation of a village system developed during World War II.) The
nutrition programme revolves around five intervention schemes: health protection,
food assistance, food production, nutrition education and family planning. The help
and co-operation of the traditional midwives has been obtained. The schools have
been drawn into health and nutrition education and the promotion of school and
family gardens. ’

Senegal. A scheme for administrative decentralization beginning in the Thids
region has, since 1973, been the base for extending village-level services to groups of
rural communities each with about 10,000 population. The Khombole health
demonstration unit has been working for many years in this region, and health ser­
vices were one of the starting points. One of the first priorities was “rural mater­
nities’ ' constructed in the traditional way and staffed by trained traditional midwives
or auxiliary midwives. Auxiliary workers (monitrices rurales) promote child-care,
hygiene, and home crafts at the village level. Small community pharmacies are pro­
vided and volunteers are trained to staff them. Wells are being dug and protected.
milling machines are one of the means of alleviating the tasks of women. A
malnutrition prevention and rehabilitation programme is being introduced following
the 1975 regional seminar in Upper Volta.
These services are now being developed in the second decentralization region,
Sine-Saloum, and a third region Ojourbel is being added.

Sudan. A “country health planning exercise” undertaken with WHO's assistance
during 1975 is leading to the adoption of a "primary health-care services” approach.
Thailand. In Lampang province (population 600,000) a pilot project is being used
to try out new methods of delivery of health services before they are applied to the
rest of the country. The object is to increase the output without an extraordinary in­
crease in the government health budget, and to serve at least two-thirds of the
women of child-bearing age and children under six. There is a focus on maternal and
child health, family planning and nutrition services. The existing health structure is
being extended by the introduction of "paraphysicians” for the health centre and
sub-centres; “health post volunteers”, one to each village; volunteer "communi­
cators”, one for every 10 or 12 households to provide a link between the patient-con9.

28

Florentino S. Solon, The Philippine Nutrition Programme - A government and private
effort. Les Carnets de 1’enfance. No. 35, pp.72-79.

I

timer and the government provider; and the training of indigenous midwives.

After orientation meetings with officials at the various levels and the village coun­
cils, village advisory committees have been set up to participate in health planning,
personnel selection and management decisions, and to provide feedback on perfor­
mance. 10
Upper Volta. In the district of Yako, response to child malnutrition during
the Sahelian drought led the health services to open nutrition recovery centres.
Under the guidance of auxiliary personnel (monitrices), mothers were shown how
to restore their children to health with a gruel made from locally available foods
(millet, niebe and palm oil). Mothers stayed at a centre, on an average, for three
weeks—"old hands" instructing new arrivals—then carried the new knowledge
back to their villages.

This method of preventing and treating malnutrition has now been incorpo­
rated into the health services. A volunteer "gruel monitrice” works in each vil­
lage, supported by auxiliary nurses in the health centre system, supervised by the
sector doctor.
Community response led to growth of the system to include training of traditional
midwives and of volunteers capable of giving first aid in the villages with a “village
pharmacy' ’. Women mobilize the families for vaccination and for malaria prevention
treatment.

The slogan of the child health committee of Yako is “health - nutrition development". In some villages, development has gone on to well digging, increased
production of the »;//>/'bean, and improvement of access roads. Following a regional
seminar, this approach is being extended to other parts of Upper Volta and is being
taken up by neighbouring countries. 11
Yemen Arab Republic. Local development councils are involving villagers in their
water supply projects, to educate them about the importance to their health of clean
water and environmental sanitation and to encourage them to maintain the water
system. The water projects serve as focal points for community participation in
starting other services, especially the rural primary health care programme which is
getting under way as part of the Second National Development Plan.
10. Somboon Vachrotai and Lampang Project Staff, The Lampang Project, an alternative
approach to rural health care in Thailand. Les Carnets de 1’enfance, No. 33, pp.88-96.
11. Cyrillc Niameogo, Les monitrices de bouillics en zones rurales de Haute-Volta, Les Carnets
de 1’enfance, No. 35, pp.31-40.

29

FOR FURTHER INFORMATION
Following is a selection from the many publications bearing on different aspects of
basic services. UNICEF field offices can assist ministries and training and research in­
stitutions in obtaining them. When translations are available, this is indicated by
E.F.S. for English, French and Spanish respectively.
Health
"Alternative Approaches to Meeting Basic Health Needs in Developing Countries", edited by
V. Djukanovic and E.P. Mach, a joint UNICEF/WHO study. World Health Organization,
Geneva. 1975, 116p.,F.S.

"Health by the People”, edited by Kenneth W. Newell, World Health Organization, Geneva,
1975, 2O6p„ F.S.

"Paediatric Priorities in the Developing World”, David Morley, Butterworth, London, 1973,
470p.
"Health”. Sector Policy Paper, World Bank, Washington D.C., 1975, 83p., F.S.

“Alternative Approaches to Health Care”, Les Carnets de 1’enfancc/Assignment Children.
No. 33,January/March 1976, UNICEF, Geneva, 136p. E.F.S. summaries.

"Health Services and Medical Education, a Programme for Immediate Action”, report of a
Group on Medical Education and Support Manpower. Ministry of Health and Family Plan­
ning, India, Indian Council of Social Science Research, New Delhi, 1975, 56p.
“Action for Children: Towards an Optimum Child Care Package in Africa”, edited by Olle
Nordberg, Peter Phillips, and Goran Sterky, Dag HammarskjSld Foundation, Uppsala 1975,
238p.

"The Primary Health Worker, Working Guide. Guidelines for Training, Guidelines for Adap­
tation”, Working document HMD/74.5, World Health Organization, Geneva, Rev. 1976,
338pp. F. ("L'agent de sante communautaire”)
“The child in the health centre, book one: A manual for health workers and a component of a
child care package”, Lembaga Kesehatan Nasional, Indonesia, Government Printer, Jakarta,
1974, 554p.,E.

“Child health care in rural areas, a manual for auxiliary nurse midwives”, Rural Health Re­
search Centre Narangwal, Asia Publishing House, Bombay, New York, 1974, 364p.
"Donde no hay doctor, una guia para los campesinos que viven lejos de los centros medicos”
David Werner, Editoral Pax, Mexico, revised 1975, 300p.

“A model health centre, a report of the working party appointed in 1972 by the Medical Com­
mittee of the Conference of Missionary Societies in Great Britian and Ireland” R.K. Hudson,
London. 1975, 16p. (appendices 1-52).

30

“Low Cost Rural Health Care and Health Manpower Training”, an annotated bibliography
with special emphasis on developing countries by Shahid Akhtar, International Development
Research Centre. Ottawa, 1975, 164p.

“The training of auxiliaries in health care, an annotated bibliography" compiled by Katherine
Elliott, Intermediate Technology Publications Ltd., London, 1975, llOp.

"Manuel de Reference Destine aux Auxiliaires Sanitaires et aux Enseignants Charges de leur
Formation” World Health Organization, Geneva, Revised 1976.
“A composite list of equipment and supplies for peripheral health facilieies, UNICEF guide
list "Rani”, UNICEF, New York, 1976, 90p.
“Provisional Reference List of Equipment and Supplies for Peripheral Health Services”
(SHS/75.2) WHO, Geneva 1975, 82p.

Water
“Water and community development”, Les Carnets de 1’enfance/Assignment Children,
No. 34, April-June 1976, UNICEF, Geneva, 136pp. E.F.S. summaries.
“Village Water Supply, a World Bank paper”, World Bank, Washington D.C., 1976, 96p.,
F.S.
“Village Water Supply, Economics and Policy in the Developing World” by Robert J.
Saunders and Jeremy J. Warford, published for the World Bank byJohns Hopkins, Baltimore.
1976, 279p.
“Water Treatment and Sanitation’ ’, a manual of simple methods for rural areas of developing
countries. Intermediate Technology Publications, London revised edition 1976.
“Rural water supply and sanitation in the developing countries”, UNICEF guide list "Olga”,
prepared in consultation with WHO, UNICEF, New York, 1975, 324p.

Nutrition
"Manual, on Feeding Infants and Young Children”, Margaret Cameron and Yngve
Hofvander, 2nd edition, PAG, United Nations. New York, 1976. 184p.
“The Feeding and Care of Infants and Young Children”. Shanti Ghosh (an adaptation and
extension of the above manual for India) UNICEF, New Delhi, 1976, 1 lOp.

“Nutrition in Preventive Medicine” edited by G.H. Beaton and I.M. Bengoa, WHO Mono­
graph, No. 62, Geneva, 1976, 590p.
“Nutrition in the Community, a text for public health workers”, edited by Donald S.
McLaren, John Wiley, London, 1976, 393p.
“National Food and Nutrition Policies”, (tentative title), edited by Jean Mayer, Oxford Uni­
versity Press, New York, 1977 (in preparation).

31

"Nutrition for Developing Countries, with special reference to the maize, cassava and millet
areas of Africa”. Maurice King, Oxford University Press. Nairobi. 1972. 234p.
“Nutrition and Village Resources”. Les Carnets de I'enfance/Assignment Children, No. 35.
July-September. 1976. UNICEF. Geneva. 136p. E.F.S. summaries.
“Control of Nutritional Anaemia, with Special Reference.to Iron Deficiency". Report of an
lAEA/USAID/WHOJoint Meeting. WHO Technical Report Series 580. Geneva. 1975. 72p.

“Vitamin A Deficiency and Xerophthalmia". Report of a Joint WHO/USAID Meeting.
WHO Technical Report Series 590. Geneva. 1976. 88p.
“New Food Policies”. Les Carnets de I'enfance/Assignment Children. No. 31 .July-September
1975. UNICEF, Geneva. 136pp. E.F.S. summaries.
"Village nutrition studies, an annotated bibliography", compiled by Sue Schofield and edited
by C.M. Lambert. Village Studies Programme. Institute of Development Studies. University
of Sussex. 1975. 285p.

Education
"New Paths to Learning: For Rural Children and Youth". Philip H. Coombs. International
Council for Education Development. 1973. 133p.
"Attacking Rural Poverty: How Non-formal Education Can Help”, Philip H. Coombs. Johns
Hopkins University Press. Baltimore, 1974, 292p.

"Education for Rural Development: Case Studies for Planners”, edited by. Manzoor Ahmed
and Philip H. Coombs. Praeger. New York. 1975. 664p.

"Basic Education in Eastern Africa”, report on a seminar sponsored by UNESCO and
UNICEF. UNICEF. Nairobi. 1975. 175p. F.

"Education", Sector Policy Paper. World Bank. Washington. D.C., 1974, 74p. F.S.

"Equality, Quality and Quantity: The Elusive Triangle in Indian Education”, J.P. Naik,
Allied Publishers, New Delhi. 1975. 142p.
"Preparation for Understanding, Helping Children to Discover Order in the World Around
Them, activities designed to avoid the use of too many words”. Keith Warren, drawings.by
Julia Warren. UNICEF, New Delhi. 1975.
"Using Science Apparatus”, a guide for primary and lower secondary teachers on how to use
local and simple imported materials, produced in consultation with UNESCO. UNICEF, New
York, 1974, 230p.

General
“Small is Beautiful. Economics as if People Mattered”, by E.F. Schumacher, Blond and
Briggs, London, Harper Colophon. New York. 1973. 290p.

32

"Rural Development”, Sector Policy Paper, World Bank, Washington D.C.. 1975. 90p. F.S.
‘ 'Employment, Growth, and Basic Needs’', International Labour Office, Geneva, 1976, 177p.

"What Now: Another Development”, a double issue of Development Dialogue, Dag Hammarskjold Foundation, Uppsala. 1975, 128p. F.S.
"Popular Participation in Decision Making for Development”, UN Department of Economic
and Social Affairs, United Nations, Sales No. E.75.IV.10, New York, 1975, 65p.
“People Power: Community Participation in the Planning and Implementation of Human
Settlements" by Mary R. Hollnsteiner, Institute of Philippine Culture, Ateneo de Manila,
Manila, 1976, 36p.
“The Young Child, Approaches to Action in Developing Countries”, UNICEF, New York (in
preparation).
"Women in Rural Development, a survey of the roles of women in Ghana, Lesotho, Kenya,
Nigeria, Bolivia, Paraguay and Peru”, Donald R. Mickelwait, Mary A. Riegelman and
Charles F. Sweet, Westview Press, Boulder, Colorado, 1976, 224p.

"Women and Development”, UNICEF guide list "Isis”, prepared in consultation with ILO,
FAO, UNESCO and WHO, UNICEF, New York, 1975. A bibliographical supplement will be
published in Spring 1977.

"Appropriate Technology, Problems and Promises”, edited by Nicolas Jequier, Development
Centre of the Organisation for Economic Co-operation and Development, Paris, 1976. 344 p. F.
"VillageTechnology Handbook”, Volunteers inTechnical Assistance (VITA) Mt. Rainier, Md.
208822, revised edition. 1976, 387p. F.S.

"Appropriate Technology,” published quarterly by Intermediate Technology Publications
Limited, 9 King Street. London. England.
"Appropriate Technology Handbook, a guide to plans and methods for village and inter­
mediate technology", by Kenneth Darrow and Rick Pam Volunteers in Asia, Box 4543, Stan­
ford, Calif. 1975, 74p.

"First Steps in Village Mechanization”, step by step instructions by George A. MacPherson,
Tanzania Publishing House, Dar-es-Salaam, 1975, 232p.
"Carts”, Dimensional drawings/photoprints. Intermediate Technology Publications, London,
1976.

33

This booklet has been prepared by
the United Nations Children’s Fund
to help governments adopt a strategy
for basic services, based on village or
community workers. UNICEF’S exper­
ience during more than thirty years
shows that sen'ices for children are
often the leading edge for improving
conditions of life in rural communiries
and poorer urban neighbourhoods. At
the same time, governments are likely
to begin children's services as part of
basic sen-ices needed to meet the needs
of an entire community.

United Nations Childrens Fund
United Nations, N.Y.
Media
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