Investments in education create economic opportunities. The poor benefit most from basic education—rates of return are higher for primary education than for secondary. And developing countries are spending more on education, particularly primary education (table 2.7). Between 1980 and 1992 spending on primary education as a share of GDP increased in roughly four of every 10 countries. The impact of education spending depends on how and on what it is spent. Governments spend little on instructional materials, however, even though they have been shown to have a consistently positive effect on student achievement in developing countries (Lockheed, Verspoor, and associates 1991). Of the countries for which information is available, 90 percent direct less than 5 percent of primary and secondary education spending to teaching materials.

Because most students in postprimary education come from better-off families, skewing education spending toward primary education can increase the access of the poor to education. But despite increased expenditures on education in recent years, particularly primary education, many countries still suffer from low enrollment rates (table 2.8). In primary schools low enrollment typically reflects underenrollment of the poor, but it also has gender dimensions, reflecting mainly cultural norms and the value of female contributions to the household (Schultz 1993; and Hill and King 1993). One consequence of this long-standing imbalance is that almost two-thirds of the world's illiterate adults—565 million—are women (table 2b).

Why does girls' education matter? Social returns to investments in female education are significantly greater than for similar investments in males, while private returns are the same or slightly higher (Heyneman 1996; Hill and King 1993; and Psacharopoulos 1994). Gender differences in persistence to grade 4 and in progression to secondary school are marginal in most countries, with rates for girls increasingly exceeding those for boys (table 2.9). Girls who enter school are more likely than boys to do so because of a strong motivation to obtain schooling or their parents' desire that they be educated—and so are more likely to complete their schooling. Women are not easily able to translate their educational achievements into social and economic gains, however. They are increasingly concentrated at the lower end of the professional ladder, often filling vacancies left by men as they move to better jobs (table 2.10).

Table 2b Estimated illiterate population aged 15 and above, 1980 and 1995
millions

Note: Some of the increase in the estimated illiterate population from 1980 to 1995 may reflect better reporting. The regional groupings are based on the United Nations country classification. Bulgaria, the former Czechoslovakia, Romania, and the former Soviet Union are included with developed countries.

Source: UNESCO 1995b.

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Along with education, improvements in health status and nutrition directly address the worst aspects of poverty. Access of the poor to health services is important both for increasing their income (illness reduces people's capacity to work) and for raising living standards even if income remains at poverty levels.

The public sector has been dominant in health improvements—training medical personnel, investing in clinics and hospitals, running subsidy and insurance schemes, and directly providing medical care. Government efforts have helped increase the number of doctors, nurses, and hospital beds throughout the developing world (table 2.11). But in many low-income countries private spending on health exceeds public spending, reflecting the inefficiency of the public system (with the distribution of political power explaining much of the allocation of resources) and ineffective social insurance systems (World Bank 1993c). The weakness of the health network means that patients seek care in hospitals or from private practitioners. Because the poor have worse access to health care, they generally use fewer health services.

Under the Health for All by the Year 2000 initiative adopted by the World Health Assembly in 1981, many developing countries are taking an important step in reducing inequities by emphasizing primary health care, including immunization, sanitation, access to safe water, family planning services, and safe motherhood initiatives (table 2.12). Even so, much remains to be done. Malnutrition, especially in women and children, remains a burden. And although the rate of measles immunization worldwide is 80 percent, ranging between 60 percent in Sub-Saharan Africa and 89 percent in the Middle East and North Africa, more than one million children are killed by the disease every year. Another 43 million cases occur annually, leaving many of the survivors prey to malnutrition and other debilitating conditions.

While most public health efforts have emphasized infant and child health, adult health is becoming a new issue for public health policy in developing countries. More than a third of the population in developing countries is between the ages of 15 and 60. The loss of an adult income earner not only may affect the family—by pushing the whole household into poverty—it also affects the economy. Adult mortality rates are highest in Sub-Saharan Africa and South Asia, where poverty is also the worst. Communicable diseases are still common. AIDS has emerged as a serious threat in developing countries, especially among people between the ages of 15 and 54. The rising consumption of tobacco in developing countries also adds to ill health. And as populations age, health care systems have to cope more with noncommunicable diseases, such as heart attacks and strokes, which are expensive to treat and can absorb considerable public health care resources for relatively small gains in overall health status (tables 2.13 and 2.14).

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Much has already been done to increase investments in human capital worldwide. Where necessary and possible, governments will also have to effectively mobilize private resources, while continuing to play a major role themselves if progress is to be sustained. But results do not depend on more resources alone; they also depend on how well resources are used and how successfully intersectoral linkages are exploited.

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