A national economy which is dependent on income from just one source is vulnerable, especially when that income comes from non-renewable resources. The sustainable prosperity of an economy thus relies on the successful implementation of economic diversification. Diversification is key to creating an attractive, flourishing environment in a country and improving the quality of its institutions and its citizens’ lives. The countries of the Gulf Cooperation Council (GCC) are accelerating their efforts to achieve economic diversification, with their national visions reflecting a shared aim of securing permanent high standards of living for future generations. After the first boom in oil prices in 1970, Saudi Arabia’s government introduced primary development plans to diversify its economy. In 2016, it announced its 2030 vision to establish sustainable growth through economic diversification. The economic diversification strategy of Saudi Arabia is founded on several pillars, including investment in human capital and education and investment in non-oil sectors such as tourism. This paper aims to analyze the economic diversification trends in the GCC region with a special focus on Saudi Arabia as a case study. Within this wider context, the paper will concentrate on Saudi Arabia’s efforts to achieve diversification by building a knowledge-based economy. Focusing on the quality of education and research improves the human capital available in the country which contributes to the growth of the economy. Results reveal that although Saudi Arabia has embarked on its diversification plans, the current status of oil prices, the deficit in the Saudi general budget, and the country’s traditional educational system will hinder and slow this process. In the early years of the 1930s, the discovery of oil in the GCC region represented a turning point for the six sheikhdoms: Kuwait, Qatar, Bahrain, UAE, Oman, and Saudi Arabia. Once composed of hermetic, nomadic, and illiterate communities, they have transformed into states that are characterized by major growth and high energy consumption. As the control of the oil industry moved to the GCC sheikhdoms under the process of nationalization, these monarchies initially fixed the prices of energy products and services at a low level. The increase in oil prices led to an increase of oil revenues and the consolidation of autocratic regimes. Oil was considered by these ruling elites as the core of their regimes’ existence and the foundation of their economic prosperity. Since these countries were founded on a patronage system, heavily reliant on the use of subsidies, a new social contract was needed between the GCC rulers and their populations which was based on rents. That is, rulers would distribute parts of the rents emanating from oil revenues to their subjects/citizens in return for the consolidation of popular support for the ruling sheiks. Hvidt [However, this process had its price. Despite the golden façade of these Gulf rentier states, the weakness of the system is apparent in the countries’ inability to withstand fluctuations in international oil prices. Hvidt  believesThis paper is organized as follows. It begins with a description of the methodology and the conceptual framework that underpin the study, including definitions of the key concept of economic diversification and other relevant terms. A sketch of the historical situation then provides an overview of the main economic diversification trends in the GCC states. The following two sections focus on the process of economic diversification in Saudi Arabia as outlined by its national Vision 2030 and analyze this economic diversification through the lens of efforts to establish a knowledge-based economy. The paper ends with some brief conclusions.Examining and exploring diversification trends in the GCC, and in particular the trajectory of economic diversification in Saudi Arabia, is the principal goal of this paper. In addition, it studies the progress of this strategy and sheds light on the factors that have played a role in delaying its achievement. Economic diversification in Saudi Arabia started in 1970 and was further consolidated in April 2016 in the Saudi Vision 2030 . In the 1Research methodology is defined by Bhujanga Rao  as “an aAchieving economic diversification has a positive impact on the sustainable growth and prosperity of a nation. To construct a comprehensive understanding of economic diversification, this paper will begin by defining the concept of economic diversification and scrutinizing the definitions of several related terms. In the context of the Gulf region, economic diversification refers to reducing the dependence of its economy on hydrocarbon resources such as oil and gas. Being dependent on a single source for revenue directly impacts the economy, linking it to the price of this principal source. In this region, consumption levels and population growth are putting increasing pressure on the depleted resources in the Gulf. The GCC countries are facing a future in which local consumption of energy resources will surpass the foreign demand for these resources, jeopardizing the whole basis of the region’s economy.Economic diversification refers to the transformation of an economy that is reliant on a specific source for its income (oil and gas revenues as in the case of the GCC countries), into an economy in which other sectors, including non-hydrocarbons, play a significant role. Examples of non-hydrocarbon fields might include industry, agriculture, and tourism. For the GCC states, economic diversification aims to minimize the risks which are associated with oil price fluctuations, by reducing their reliance on a single finite resource and instead dispersing it across multiple potentially infinite resources . The expEconomic diversification also paves the way for the accomplishment of the UN’s Sustainable Development Goals (SDGs). The SDGs comprise 17 goals which were agreed upon in 2015 by all UN member states, to be achieved by 2030, within the “2030 Agenda for Sustainable Development” . The UN Economic diversification consolidates the economic and financial foundations of a country . If one The increased engagement of the private sector can be expected to lead to further economic diversification, for example, through a process of privatization and through Public–Private Partnership programs (PPPs)  which woIn this context, it should be noted that the public sector in the GCC region is currently the main source of employment. Levels of bureaucracy in this sector are high, with resultant high costs . This caInvestment in human capital, meanwhile, requires reform in the educational process to create specialized and highly qualified citizens. Mishrif and Al Balushi  point ouOzili  defines Economic diversification occurs in two directions—vertical and horizontal. Vertical diversification concentrates the process of expansion within a sector by introducing additional steps. Hvidt  argues tHorizontal diversification, on the other hand, entails the expansion of different possibilities for innovative products. Recently, the GCC countries have turned to this category of diversification as illustrated by their investments in non-hydrocarbon fields such as culture, tourism, and sport. Although there is a tendency to use the terms economic diversification and industrialization interchangeably, there is a difference. According to Hvidt , industrThe Gulf region’s pre-oil economy depended mainly on the fishing industry and pearl diving trade. This region did not establish agriculture due to the harsh climate and the scarcity of the necessary natural resources. Krane  depicts Economic diversification started in the GCC region in the 1970s, during a period of high oil prices. At that time, Saudi Arabia embarked on its diversification plans to earn revenues from non-oil resources, focusing on fiscal revenues. Hvidt . There iSince oil was first discovered in the region, the economy of Saudi Arabia has been dependent on oil revenues. Saudi Arabia possesses about 30% of global crude oil and is ranked second in terms of the global production of crude oil. It also has 22% of proven gas reserves, ranked sixth in the world , with thThis recent snapshot of the Saudi economy contrasts with the ambitious Saudi National Vision 2030 . The essIf creating a knowledge-based economy is the cognitive bridge to creating a diversified economy, then educational reform and investment in R&D provide the infrastructure for building that knowledge-based economy, which would enable Saudi Arabia to transition away from an oil-based economy. Wirba  argues tAs discussed above, constructing a knowledge-based economy requires that citizens are equipped with analytical skills and other key abilities that are demanded by the private sector and are needed to function in a globalized market. Improving the quality of education requires investment in education and the setting up of research institutions. This in turn demands a clear and measurable educational vision. If successful, educational reform will expand knowledge through unlimited access to information sources. Furthermore, it will distribute educational roles among multiple players, including the engagement of the private sector, working with the education ministry.Saudi Arabia is the largest GCC country in terms of geography and population, which could be an asset in terms of building a knowledge-based economy; moreover, it is one of only two GCC countries in which nationals outnumber foreigners, accounting for 69% of the population . To moveCowan  estimateThe principal aim of economic diversification is to make the economy resilient and robust. A strategy of economic diversification can sustain economic growth and minimize the risks of over-reliance on one sector. Recently, the GCC countries have started to look beyond their dependence on oil revenues, with ambitious national visions reflecting their plans for economic diversification. Saudi Arabia’s National Vision 2030  declared


Home visits by community health workers are promoted to improve the coverage and uptake of evidence-based newborn services and behaviours. However, evidence on the effectiveness of these home visits delivered through government systems at scale is limited, as is evidence from the post-neonatal period. From 2013 to 2017, the Government of India piloted an intervention called Home Based Newborn Care Plus with the goal of reducing pneumonia- and diarrhoea-related morbidity and malnutrition. Village-based Accredited Social Health Activists were incentivised to make quarterly home visits to infants between three and 12 months of age. After the pilot, the intervention was adapted and scaled up nationally  as a new programme called Home Based Care for Young Child.The study used a quasi-experimental, difference-in-differences method to assess the quantitative impact on key outcome indicators by comparing changes over time in treatment districts with matched control districts. This was supplemented by a quantitative health worker survey and qualitative data collected at worker and community level.The intervention led to a significant increase in the number of home visits, and their content became more aligned with Home Based Newborn Care Plus protocols. However, absolute levels of coverage remained low. The intervention had no detectable effect on the key outcomes of feeding practices, handwashing, iron and folic acid and oral rehydration solution supplementation, growth monitoring, and immunisation.Given the scale up of Home-Based Care for Young Child, there is a need to identify appropriate and comprehensive support for Accredited Social Health Activists to attain high coverage and quality and deliver impact. This will require reconsidering current design elements (such as incentives) and solving the underlying demand side and system level challenges (such as workload and supply chains) constraining Accredited Social Health Activists. Community health workers (CHWs) are acknowledged to play a critical role in promoting the uptake of health services and the adoption of appropriate behaviours ,2, partiHome visits after childbirth by CHWs are promoted as an evidence-based strategy to reduce newborn mortality and improve key newborn care practices and outcomes in high mortality settings . For exaHowever, much of the evidence on the effectiveness of home visits comes from small scale pilots implemented in highly controlled field settings with the help of non-governmental organisations . This stFurther, whilst home visits in the neonatal period, in conjunction with other interventions, have been shown to increase care seeking for diarrhoea and pneumonia and reduce morbidity in the post-neonatal period, including in India , few stuSince 2010, CHWs in India in the form of Accredited Social Health Activists (ASHAs) have been mandated to make home visits for newborn care under a programme called Home Based Newborn Care (HBNC). ASHAs are trained female volunteers chosen from within the community, covering a population of 1000 beneficiaries . In mostFrom 2013 until 2017, the Government of India piloted an extension of HBNC, termed HBNC+, to focus on post-neonatal and infant health so that home visits could also be provided by ASHAs to infants up until the age of one. This was piloted in 13 districts in the four states of Bihar, Odisha, Madhya Pradesh and Rajasthan , with a combined population of 20.6 million in 2011. After the pilot, the intervention has now been adapted and scaled up nationally (with the addition of one visit at 15 months of age) as Home Based Care for Young Child (HBYC) [HBNC+ was piloted with the support of the Norway India Partnership Initiative (NIPI). The broader NIPI programme focused on supporting the Government of India’s National Health Mission (NHM) to pilot continuum of care innovations at the community and facility level .The HBNC+ intervention packaged multiple evidence-based interventions for improving the survival and development of infants through additional incentivised, structured home visits by ASHAs at three, six, nine, and 12 months of age. HBNC+ targeted the prevention of pneumonia- and diarrhoea-related morbidity and malnutrition. As such, it did not focus on the assessment, classification, referral and treatment of sick infants. The home visits were expected to promote exclusive breastfeeding for the first six months after childbirth, ensure continued breastfeeding and complementary feeding from six months, promote routine child immunisation, provide counselling for handwashing, facilitate the distribution of oral rehydration solution (ORS) and iron and folic acid (IFA) syrup, ensure regular growth monitoring, and promote Early Child Care and Development (ECCD) .Under the existing NHM protocol, ASHAs were already expected to make monthly home visits to households with infants. The additionality of HBNC+ was a focused push to ensure that home visits happened at key moments of a child’s growth with key target messages. This was to be achieved through the training of ASHAs in the HBNC+ protocol and by the provision of incentives  to ASHAs for the successful completion of four visits, as per the defined schedule. For a typical ASHA’s catchment area in the programme states, HBNC+ would require ten home visits per month, on top of the sixteen required for HBNC .The effectiveness of HBNC+ was evaluated using a mixed methods approach, combining both quantitative and qualitative methods. This paper presents a subset of the broader evaluation undertaken by Oxford Policy Management and Sambodhi Research and Communications . The evaThe evaluation was structured around two core research questions at the population level:Coverage and quality: Did the programme inputs and processes (training and incentives) lead to additional outputs in the form of home visits by ASHAs to target households according to the HBNC+ protocol?Outcomes: Did the home visits lead to improved preventive health practices , improved interaction with the child (through ECCD), increased use of products (ORS and iron supplementation), and service uptake (growth monitoring and full immunisation)?Although the final goal of the programme was to reduce disease morbidity and infant mortality, the evaluability of these impact indicators was constrained by long transmission mechanisms, small effect sizes, and overarching confounding factors. Therefore, the evaluation investigated the impact of the programme only as far as the output and the outcome level  of the results chain.The quantitative impact evaluation involved primary data collection at the population and health worker level, and the qualitative impact evaluation involved data collected through focus group discussions (FGDs) with mothers and in-depth interviews (IDIs) with ASHAs. Fieldwork was undertaken in December 2013-January 2014 (baseline) and January-February 2017 (endline). Data was collected by Sambodhi Research and Communications.The quantitative evaluation at the population level was based on two cross-sectional population surveys of mothers of children between 3 and 23 months at baseline and endline, across a panel of primary sampling units (PSUs) of villages in treatment and control areas. The PSUs and mothers were selected based on the following steps:.Step 1: Given that the programme had already selected the 13 treatment districts, control districts were chosen from a matching exercise to minimise the effect of confounding factors and create a comparable comparison group. The treatment and control districts were matched based on literacy rate, levels of urbanisation, the proportion of Scheduled Castes, and population density. Treatment and control districts are shown in Step 2: From each treatment district, two sub-districts were randomly sampled and matched with two sub-districts from the matched control district, based on the factors listed above (excluding population density), using the minimum difference approach . For eacStep 3: From each sampled sub-district, six PSUs were selected using the probability proportional-to-size (PPS) method. PPS is a simple sampling technique whereby the probability of selection of a unit is proportional to its size. PPS ensures the representativeness of the sample if the sampling units vary in size.Step 4: From each PSU, 15 households with mothers of children between 3 and 24 months of age were randomly selected after a listing exercise.At baseline, the total sample was 3935 children between 3 and 23 months of age (1948 in the treatment group and 1987 in the control group). At endline, the total sample was 4049 (1985 in the treatment group and 2064 in the control group). Based on the power calculations conducted at baseline, this gave a minimum detectable effect for a standard indicator of five percentage points at the programme level and ten percentage points at the state level (with the assumptions of a 50% baseline outcome level and design effect of 2.0).The impact of HBNC+ on programme outcomes was identified using a quasi-experimental methodology of difference-in-differences (diff-in-diff). This compared changes over time in outcomes in treatment areas which received HBNC+ with changes in matched control areas where HBNC+ was not implemented. This approach removes biases arising from time-invariant, group-specific, unobserved factors. The diff-in-diff specification can be represented as follows:ijts = β0 + β1dTj + β2dPostt + β3y(tdPost)(jdT)4Xi + θs + εijt + βijtsy is the outcome of interest for individual i at time t in village j and state s. The dummy variable dT equals 1 if the individual is residing in a treatment village and 0 for a control village. The time dummy variable dPost equals 1 if the time period is 2017 (endline) and 0 for 2013 (baseline). The main parameter of interest is 3β, the coefficient on the interaction term, (tdPost)(jdT). This parameter represents the intention to treat effect, measuring the average effect of the intervention on all households eligible to receive the intervention, whether or not they receive the intervention, and hence provides an unbiased estimate of effectiveness of HBNC+. iX is a vector of the individual characteristics of the mother and the household within which she resides. The choice of covariates was theory-based and included: the age and gender of her child; her own age and education level ; the number of previous childbirths; whether the birth took place in a health institution; the frequency of her ANC visits (whether it was between one and three visits or more than four); the age, gender, education level, religion, and caste of the household head; the number of females and the total size of the household; the household wealth index quintile category; and distance and family barriers to health care access. sθ refer to state-specific fixed effects. The standard errors are clustered at the village level. Since non-probability based matching techniques were used for identification purposes, we do not use probability weights and therefore the estimates apply to the impact estimation sample only. The unit of analysis is the individual/household.where The following limitations of the quantitative evaluation methodology should be acknowledged whilst interpreting its findings:The evaluation is not powered to detect effects on morbidity or mortality; therefore, it can only measure up to the level of ‘outcomes’ in the theory of change. Some outcome estimates are also hampered by small sample sizes  and are therefore not powered to detect statistically significant changes.The sampling strategy was defined to increase the likelihood of sound comparability between the treatment and control groups by allowing for the matching of districts and sub-divisions based on secondary data sources. The baseline study confirmed that there was no statistically significant difference between the treatment and control areas for the key indicators, lending robustness to the evaluation . Key infDue to the changes to the data collection tools between baseline and endline, the diff-in-diff methodology cannot be used for some indicators. As a result, two outcome indicators rely on single difference estimates and therefore offer weaker causal attribution: (a) the ORS component of the programme was scaled up nationally, and as a result the impact analysis is pre-post covering only the treatment areas; and (b) the understanding that IFA distribution was part of the intervention was understood by the evaluation team only after the baseline data collection and, consequently, the evaluation is ex-post only, comparing treatment and control areas.Outcomes related to ECCD are difficult to measure. For this paper, we used a crude indicator, constructed from a straightforward question asked of the mother about the method of interaction with her child, with options of talking/playing/listening  to her child.There are typical risks of inaccurate self-reporting of behaviours and service uptake and socially desirable answers that are inherent in health surveys at the population level.The quantitative evaluation at the health worker level included a provider survey of ASHAs from each of the PSUs of the population survey. Each PSU represented one ASHA catchment area, so no further sampling was required. The evaluation measured their receipt of inputs, knowledge, and reported levels of service and product availability. 300 ASHAs were covered at baseline  and 304 at endline . This sample was not intended to achieve statistical significance.The qualitative data collected was collected at endline and has two data sources – FGDs with mothers and IDIs with ASHAs. Qualitative data was analysed through thematic framework analysis.Twenty-six FGDs were held with mothers who had children younger than two years of age. These FGDs were held in 13 treatment districts across the four states, with two FGDs being conducted per district. FGDs explored themes such as the challenges of looking after infants; the treatment-seeking behaviour of mothers; the perception of services provided by health workers; women’s decision making; their status in the household; and their attitudes and practices related to family planning. A total of 170 women participated in the FGDs across the four states and the size of the FGDs ranged from 5 to 11 mothers.IDIs were held with ASHAs to investigate issues such as her work schedule, roles and responsibilities, motivation and incentives, and attitudes and practices related to family planning. The data was collected from 26 ASHAs, with two ASHAs being interviewed from each of the 13 districts.Ethical permission for the evaluation was granted by the independent ethics review board of the Public Healthcare Society (India). The evaluation was conducted to the highest ethical standards. This included ensuring that expectations of the participants were not raised, confidentiality was maintained, and respondents were informed about the purpose of the survey and asked to participate voluntarily. Informed verbal consent was obtained from the research subjects. Only female interviewers took the consent and interviewed the female respondents. No personal identifiers were used in any form of reporting or dissemination. Personal identifications were linked with a unique identifier and were kept securely. No information was published that could identify the respondents. Paper copies of questionnaires were stored for three years in a secure location before being destroyed; only the investigation team were able to access them. Participation in the research was voluntary and respondents were free to stop the interviews at any time or skip any questions they did not want to answer. They had the right to ask questions at any point before, during, or after the interview was completed. The research staff and the participants were informed about the purpose, methods, benefits, and intended possible uses of the research. All interviews were conducted by trained staff members and in conditions of privacy.At endline, 95% of ASHAs had received training on HBNC+. Their level of programme awareness was very high, with 93% reporting the correct number of home visits they were expected to make, and 92% the correct schedule for these visits.While the pilot target was for at least 80% of children to receive at least one HBNC+ visit, at endline, it was found that 69% of children in the treatment areas aged 12–23 months had received at least one visit between the ages of three and twelve months, and that only 39% received all four visits as per the schedule. Sub-group analysis shows no evidence of systematic exclusion based on caste, birth order, or wealth in treatment areas at endline (results not shown).Given that NHM already mandated ASHAs to make general home visits during the HBNC+ period, not all the home visits recorded under HBNC+ are additional visits. As shown in The qualitative data suggests that low and delayed incentives were a driver of relatively low coverage compared to protocols and targets. Compared to incentives received from other programmes, such as institutional delivery and immunisation, most of the ASHAs reported that they were not satisfied with the low incentives received under HBNC+. As an ASHA from Madhya Pradesh said in an IDI: ‘No, I am not satisfied with the incentives, it is very less as compared to my workload’. Another ASHA from Bihar also said in an IDI: ‘Yes, it affects. If we will get good incentive, then only we would be happy in doing our work otherwise I don’t feel like working’. Some ASHAs said that they have expenses, such as travel expenses and mobile phone expenses, which were not reimbursed: ‘we have to bear our mobile expenses and conveyance’ . They also said that they did not receive incentives on time in their bank account. Complex incentive delivery systems also led to confusion over what incentives were received for which service. As stated by an ASHA from Bihar in an IDI: ‘After completing four follow up visits we get the form ready and submit it. I am eligible for incentives. We face a lot of challenges. We do not understand for which service we are getting the incentives’.In addition to the increase in the coverage of home visits, the programme also had an impact on the content of these visits. The home visits in the treatment areas were substantially more likely to adhere to HBNC+ protocol than the home visits in the control areas at endline. As shown in At the outcomes level, the impact evaluation investigated the impact of HBNC+ visits on eight key outcome indicators using the diff-in-diff methodology. As shown in However, the comparison of the endline values for IFA consumption shows a statistically significant difference, though this cannot be attributed to HBNC+ because of the lack of a counterfactual.The qualitative study explored several reasons behind this lack of improvement in outcomes. Some related to system level constraints, including a lack of coordination with and reliance on other health providers  and a lack of supplies. Nearly half of ASHAs in treatment areas reported having no stock of IFA syrup at endline, and a quarter reported having no stock of ORS.In some areas, limited ASHA knowledge may have contributed to poor outcomes. At endline in treatment areas, ASHAs were found to have high levels of knowledge about some HBNC+ components (such as 98% of ASHAs knowing that exclusive breastfeeding should continue for six months), however for other components this was much lower .Beneficiaries and ASHAs also cited practical, community-level challenges as a reason for not adhering to the behaviours promoted. For example, some mothers could not exclusively breastfeed because they could not produce milk, or because they were not the sole caregiver. As an ASHA from Rajasthan stated in an IDI: ‘Some mothers do follow but not completely. Sometime when they go to field then their mother-in-law gives water and other things to the child’.The findings demonstrate that whilst there was a statistically significant increase in the number of home visits received by mothers because of the intervention, and that the content of these visits became more aligned with HBNC+ protocol in treatment districts compared to control areas, effective coverage remained low. This finding matches closely to the figures reported by the implementing team in their 2015 Annual Report  where 66However, the evaluation demonstrates no observed impact on key outcomes. This has also been documented elsewhere. A rapid assessment of HBNC+  in RajasHowever, this evaluation has its own limitations. The evaluation is unable to assess the impact on infant mortality, as this would have required a much larger sample to detect any meaningful impact and a longer evaluation period. A second limitation of the methodological approach is that the quasi-experimental estimation requires the parallel trends assumption to be upheld. As outlined in the methodology, the PSU surveys and key informant interviews detected no confounding factors that affected the treatment and control areas differently. This gives confidence to the evaluation findings. However, we are not able to reliably test for the parallel trends assumption. The results point to other drivers of change occurring in both treatment and control areas. For example, growth monitoring improved in all areas potentially either due to strengthening of the Anganwadi programme or pan-state behavioural change communication interventions. Hence, attributing changes to some of the outcomes is not possible and also beyond the scope of the evaluation.It is also not possible to test robustly whether the lack of demonstrated effectiveness is due to low underlying efficacy of home visits  or their low effective coverage . Further research would be required to assess the underlying efficacy of these home visits and identify opportunities for strengthening them. In other contexts, home visits by ASHAs have been shown to be efficacious at influencing behaviour and care-seeking, including in the neonatal period ,24. HoweThe evaluation suggests that achieving high effective coverage at scale remains a challenge. Even at endline in the treatment areas, only 39% of children had received the programme target of four visits, despite the additional training and incentives provided under HBNC+. This is consistent with the experience of the original HBNC programme for the neonatal period. Whilst this evaluation did not assess HBNC, the surveys measured its coverage. The baseline survey showed that, despite several years of HBNC implementation, only 7% of children were receiving at least six visits after institutional delivery, and only 4% seven visits after home delivery .The baseline survey also identified issues that undermined the effectiveness of HBNC similar to those described in this evaluation of HBNC+. There were low levels of knowledge among ASHAs of the HBNC protocol, limited coverage of content during these home visits, low levels of referrals by ASHAs of children exhibiting danger signs, and low levels of patient satisfaction . ExplanaThe systemic challenges identified that undermined the effectiveness of HBNC+ – a lack of supplies and commodities, heavy workloads, low and delayed compensation, and weak training systems – mirror the most pressing challenges facing CHW programmes globally ,4. It isGiven that HBYC has already been scaled nationally, it will be important to identify ways to build functional systems and appropriately support ASHAs in attaining high coverage and quality and having maximum impact. Similar conclusions have been made in the face of the frequently disappointing results from community case management approaches to treating diarrhoea, pneumonia and malaria ,32. For For HYBC to be successful at scale, a revision to the approach to delivering appropriate and timely incentives is likely to be required. The constraining impact of ineffective incentives on home visits is well established in the literature . In IndiBeyond HBYC, whilst this evaluation provides lessons specific to a particular set of behaviours and services promoted through a specific schedule of home visits in India, the lessons on challenges to scale up of home visits by CHWs through government systems are generalized findings. The evaluation findings reinforce the need to focus not just on the intervention package but also on the broader system-level factors, particularly supply chains, supportive supervision, workload and incentives, as well as the demand-side factors, required to create an enabling environment for high coverage and quality and hence, achieve greater impact.The provision of training and incentives to ASHAs to deliver at least four visits to infants aged from three to 12 months led to a significant increase in the number of mothers receiving home visits. These home visits were also reported to be more closely following the HBNC+ protocols as measured by the reporting of different counselling messages or supplies by the mothers. However, only 39% of the women reported receiving the full schedule of HBNC+ visits, and there was no detectable effect of HBNC+ on average levels of outcomes. As HBNC+ has now been scaled nationally as HBYC, it will be important to reconsider current design elements (such as the incentive schedule) and solve the underlying demand-side constraints and systemic challenges such as workload and supply chains that will enable ASHAs to deliver HBYC at high coverage and quality at scale. Learning how to do so will require intensive concurrent monitoring, learning and evaluation. More generally, this paper contributes to the lessons on the challenges of achieving high effective coverage and quality of home visits by CHWs at scale, particularly in the post-neonatal period.


Metaphors, a ubiquitous feature of human language, reflect mappings from one conceptual domain onto another. Although founded on bidirectional relations of similarity, their linguistic expression is typically unidirectional, governed by conceptual hierarchies pertaining to abstractness, animacy and prototypicality. The unidirectional nature of metaphors is a product of various asymmetries characteristic of grammatical structure, in particular, those related to thematic role assignment. This paper argues that contemporary metaphor unidirectionality is the outcome of an evolutionary journey whose origin lies in an earlier bidirectionality. Invoking the Complexity Covariance Hypothesis governing the correlation of linguistic and socio-political complexity, the Evolutionary Inference Principle suggests that simpler linguistic structures are evolutionarily prior to more complex ones, and accordingly that bidirectional metaphors evolved at an earlier stage than unidirectional ones. This paper presents the results of an experiment comparing the degree of metaphor unidirectionality in two languages: Hebrew and Abui (spoken by some 16 000 people on the island of Alor in Indonesia). The results of the experiment show that metaphor unidirectionality is significantly higher in Hebrew than in Abui. Whereas Hebrew is a national language, Abui is a regional language of relatively low socio-political complexity. In accordance with the Evolutionary Inference Principle, the lower degree of metaphor unidirectionality of Abui may accordingly be reconstructed to an earlier stage in the evolution of language. The evolutionary journey from bidirectionality to unidirectionality in metaphors argued for here may be viewed as part of a larger package, whereby the development of grammatical complexity in various domains is driven by the incremental increases in socio-political complexity that characterize the course of human prehistory.This article is part of the theme issue ‘Reconstructing prehistoric languages’. Nevertheless, this paper suggests that it may indeed be possible to make inferences concerning the ways in which metaphors developed, within the more general course of language evolution.et al. [et al. gave their participants a task that assessed the influence of an irrelevant dimension (time or space) on a relevant dimension (space or time) and found significant cross-domain interference effects, concluding that, in this particular domain at least, rhesus monkeys do indeed connect between space and time, thereby engaging in metaphorical thought.Although metaphors are typically expressed through language, their basis is in conceptual structures, involving mappings between two distinct conceptual domains. As such, it makes sense to ask whether metaphorical thought is present among other animals, which lack language. At least one study suggests that it might be. In an investigation of rhesus monkeys, Merritt et al.  found thdirectionality.However rudimentary they may be, the metaphorical abilities of rhesus monkeys thus highlight the potential interest in evolutionarily oriented investigations of metaphoricity. In particular, they raise the questions of how the metaphorical abilities of humans differ from those of other animals, and how they might have evolved to reach their current state. One perspective on these questions is that of Benítez-Burraco & Progovac , who arg. 2bidirectional: while in some conditions a temporal stimulus affected a spatial assessment, in other conditions a spatial stimulus influenced a temporal assessment. By contrast, among humans, metaphors are pervasively unidirectional. For example, while time is often conceptualized in terms of space, space is rarely or never conceptualized in terms of time; see Boroditsky [et al. [vice versa. In language, such space–time asymmetry is reflected by numerous expressions such as long time, and on Monday, in which a temporal expression , is conceptualized by means of a spatial one , as contrasted with a dearth of mirror-image expressions in which a spatial expression would be conceptualized in terms of a temporal one.Metaphor directionality lies at the heart of human metaphorical behaviour. In the case of the rhesus monkeys mentioned above, the observed effects were roditsky , Casasanroditsky  and othe [et al.  experimetarget, the concept being explicated, and source, the concept doing the explication. For example, in metaphors connecting space and time, the spatial expression is typically the source and the temporal expression its target. The unidirectionality of metaphors is a central theme in metaphor studies, as reflected in work by Lakoff & Johnson [et al. [Metaphor directionality is rooted in various conceptual hierarchies. For example, abstract entities tend to be described in terms of more concrete ones, the above-mentioned spatial/temporal asymmetries offering a particular case of this. Similarly, in accordance with other hierarchies, more animate entities tend to be described in terms of less animate ones and less prototypical entities in terms of more prototypical ones. A common way of describing metaphor unidirectionality is in terms of the twin notions of  Johnson , Kogan e [et al. , Glucksb [et al.  and manyNotwithstanding the above, recent work suggests that the unidirectionality of metaphors rests on the foundations of a more basic bidirectionality. Logically speaking, metaphors appeal to cross-domain mappings that may potentially be defined in either direction, reflecting a fundamentally symmetric relation of similarity. Such symmetry is supported by a variety of psychophysical experiments revealing a clear bidirectional pattern for many hypothesized conceptual mappings; see Ĳzerman & Koole  for deta. 3long time, the source expression long assigns the thematic role of theme to its target expression time.A crucial factor underpinning metaphor unidirectionality is the presence of language, or, more specifically, grammar. As shown in Porat & Shen  and Shengeneral and particular directionality, respectively. General directionality represents the systematic way in which grammatical asymmetries predispose our cognitive processes towards correspondingly asymmetric conceptual hierarchies; it is, presumably, universal and invariant across different languages and cultures. By contrast, particular directionality effects are manifest in the ways in which the specific grammatical structures of languages provide further reinforcement to the same conceptual hierarchies; they may thus vary in their applicability both across different constructions within the same language, and across prima facie similar constructions in different languages.The role of grammar in introducing metaphor directionality is manifest in two distinct ways, which we refer to here as Nile, and a temporal one, Monday:The role of grammatical asymmetries in introducing metaphoricity and the distinction between general and particular directionality effects across different constructions within the same language, English, may be observed by comparing the following sentences involving a novel metaphor making use of the mapping between a spatial expression, Monday to be understood as explicated in terms of the more concrete Nile, appealing perhaps to the shared property of being long and slow-moving—under this interpretation, Nile is understood as the metaphorical source and Monday as its target. However, this preference comes up against the variegated grammatical constructions in (1) and (2), resulting in differential applications of particular directionality effects. In (1), the two terms occur in symmetric conjunctions, which, as shown by Fishman & Shen [canonical. However, in (2b), the same grammatical rules conflict with the conceptual hierarchy, resulting in a non-canonically ordered metaphor that is more difficult to process and interpret. Thus, whereas in (2a), general and particular directionality effects reinforce one another, converging to produce a canonical metaphorical construction, in (2b) they diverge, resulting in a non-canonical metaphorical construction.In accordance with general directionality, the mere presence of the grammatical medium activates the concrete/abstract conceptual hierarchy, yielding a preference for the more abstract n & Shen , are not. 4The role of grammar in introducing metaphor unidirectionality suggests that from an evolutionary perspective, bidirectionality is a living fossil, reflecting an earlier evolutionary stage, evinced by rhesus monkeys and other animals, in which grammar has not yet emerged. However, the presence of grammar also points towards a more fine-grained method of tracing the evolutionary path from bidirectionality to unidirectionality, appealing to patterns of cross-linguistic variation. In particular, given the role of grammar in inducing particular directionality effects, as in (1) and (2) above, it stands to reason that languages with different grammars may also perhaps be associated with different degrees of metaphor directionality. Moreover, if and when such differences are found, they may potentially provide a model for the evolution of metaphor directionality.Complexity Covariance Hypothesis. In such cases, it may be inferred that the simpler linguistic structures are evolutionarily prior to their more complex counterparts: the Evolutionary Inference Principle. This paper applies this method in order to adduce empirical support for the reconstruction of metaphor bidirectionality to an earlier stage in the evolution of human language.In Gil , a methoThe first step in the argumentation rests on the observation that metaphor bidirectionality is less complex than metaphor unidirectionality. This is because the relationship between the two is privative. Whereas bidirectionality may be represented as a simple symmetric juxtaposition of two terms, X ∼ Y, unidirectionality adds an additional element to the mix, namely the characterization of one of the two terms as target and the other as source; see Gil & Shen  for furtIn order to invoke the Evolutionary Inference Principle, the greater complexity of metaphor unidirectionality must be shown to correlate with some extra-linguistic measure of complexity. Whereas Gil  makes usThe above scale is of a hybrid nature, combining several measures of polity complexity. First is a basic dichotomy between national and regional languages. National languages are further distinguished with respect to more specific features pertaining to the language's functions and status. And regional languages are classified in terms of the complexity of their associated societies as reflected in the number of levels of ‘jurisdictional hierarchy beyond local community', as defined in the D-Place database .With this in hand, we may now formulate an empirical hypothesis relating to metaphor directionality and polity complexity:The above hypothesis predicts that languages with greater metaphor unidirectionality will be associated with polities of greater complexity in accordance with the scale in (3). If the hypothesis in (4) turns out to be supported, then this would provide further support for the reconstruction of metaphor bidirectionality to an earlier stage in the evolution of human language. In the next section, we provide some preliminary empirical support for the above hypothesis.. 5In order to test the hypothesis in (4), we adapted the Context Experiment first developed in Porat & Shen . In the Each stimulus consists of a metaphor asserting the similarity of two generically referring terms, followed by two expressions referring to people. The participants' task is to choose which of the two people is more likely to utter the metaphor.Forgetfulness is like a mackerel, since concrete objects are more likely to explicate abstract ones than vice versa. In the experiment, six stimuli make reference to the concrete/abstract hierarchy as in (5), six to the animacy hierarchy as in (6) and four to the prototypicality hierarchy as in (7). Of the two potential speakers that the participants must choose from, one is associated with the first of the two terms while the other is associated with the second term. (While as presented in (5)–(7) above, the (a) speaker is associated with the first term and the (b) speaker with the second term, in the actual experiment the relative order of the two speakers is randomized.)The metaphors are all novel and are not necessarily supposed to ‘make sense'. The choice of novel rather than conventionalized metaphors is intended to control for possible effects stemming from participants' differential levels of education and familiarity with the metaphors. The metaphors are all presented in the non-canonical order, that is to say, in violation of metaphor unidirectionality and the underlying conceptual hierarchies. For example, in (5), it would be more natural to say that The Context Experiment pits grammatical structures and particular directionality effects against conceptual hierarchies and the general directionality effect, posing participants with a dilemma. For example, in (5), the grammatical structure points towards the fisherman as being the speaker, since he is associated with the subject of the sentence, referring to a mackerel; however, the concrete/abstract hierarchy suggests instead that the very old man should be the speaker, since he is connected with the abstract concept of forgetfulness. Thus, by examining participants' responses to choices such as this, we may assess the contribution of grammatical asymmetries to metaphor directionality.The Context Experiment provides a tool for testing the covariation of metaphor directionality and polity complexity in accordance with the hypothesis in (4). Given the universality of the general directionality effect, the experiment provides a measure of the force of particular directionality effects as an additional contribution to overall metaphor directionality, pointing towards the following prediction:In the discussion of examples (5)–(7) above, a substantial particular directionality effect was presupposed for English; such an effect is to be expected given the status of English as a world language and its position occupying rank 1 at the top of the polity complexity scale in (3). However, in order to test the prediction in (8), particular directionality effects must be tested in a substantial sample of languages.Hebrew and Abui. Hebrew, with several million native speakers, is the national language of Israel, and accordingly occupies rank 2 on the polity complexity scale, as a primary national language. Abui, described by Kratochvíl [The experimental programme is currently in progress. At the time of writing, we have run the experiment in 10 different languages associated with varying levels of polity complexity, and initial results provide substantial support for the prediction in (8). For reasons of time and space, this paper presents results from just two of the languages, atochvíl  and Saadatochvíl , belongsSome example stimuli, the counterparts of those in (5)–(7) above, are presented below, for Hebrew in (9)–(11), and for Abui in (12)–(14):kmo ‘like', for Abui this consists of the complex verbal expression wida. As evident in the above examples, certain adjustments had to be made in order to construct comparable stimuli in languages associated with very different cultures and ecologies. To cite just one example, stimuli (7) in English, (11) in Hebrew and (14) in Abui are all intended to contrast a prototypical animal with a non-prototypical one; however, the kinds of animals and their relative degrees of prototypicality differ from place to place, as do the potentially available speakers who might be associated, through diverse cultural conventions, with the animals in question.For each of the two languages, the metaphors are couched in the most natural construction available for the asymmetric expression of similarity: while for Hebrew this involves a copula followed by the word In addition to the 16 experimental stimuli, six additional distractor stimuli were included in the experiment. These distractors contained a metaphor in canonical order, followed by two potential speakers: while one of the speakers was associated with the first term, the one in subject position functioning as the target of the metaphor, the second speaker was not associated with either of the two terms. Competent participants were therefore expected to choose the speaker associated with the first term and not the speaker associated with neither of the terms; participants failing to do so consistently were excluded as not having properly understood or sufficiently carefully performed the experimental task. The experiment was conducted online, using Google Forms, with the link being distributed mostly via Facebook and Twitter.The results of the experiment in Hebrew and Abui are summarized in p < 0.00001 (according to a one-tailed t-test). Whereas in Hebrew grammatical structure trumps conceptual hierarchies, in Abui the two are more evenly matched. , namely that particular directionality effects will be more pronounced in languages higher on the scale of polity complexity. In turn, these results lend initial support to the hypothesis in (4), to the effect that metaphor directionality covaries with polity complexity. Invoking the Evolutionary Inference Principle, the results of the Context Experiment thus provide further support for the reconstruction of metaphor bidirectionality to an earlier stage in the evolution of human language.. 6hu/hi kmo ‘is like' occurs between the two terms being compared, in Abui, with basic subject–object–verb word order, the expression wida ‘is like' occurs at the end of the clause, following the two terms being compared. A second difference pertains to flagging: whereas in Hebrew the second term in the comparison is marked with kmo ‘like', in Abui both terms occur in bare form, without any adposition or case-marking.As is evident in (9)–(14), the experimental stimuli in Hebrew and Abui differ from each other not only with respect to the words that they use, but also with regard to the grammatical structures in which these words occur. One obvious difference is in word order: while in Hebrew, with basic subject–verb–object word order, the expression The covariance between polity complexity and particular metaphor unidirectionality, as evidenced by the results of the Context Experiment, is not direct, but rather mediated by grammatical properties of the respective languages such as the ones mentioned above. A schematic representation of the relationship between polity complexity, grammar, and particular metaphor unidirectionality is provided in In The car is pushing the woman, and are asked to judge whether the sentence constitutes an appropriate description of the picture. English-speaking participants will say ‘no', because the sentence is ‘round the wrong way', English conveying the distinction between agent and patient thematic roles by means of word order. But what of the corresponding sentences in Hebrew and Abui? In Hebrew, speakers will also reject the sentence, Hamexonit doħefet et haiša, albeit for a different reason, namely the presence of the accusative preposition et flagging haiša ‘the woman', marking it as bearing the role of patient, and thereby conflicting with the picture. By contrast, in Abui, most speakers will accept the corresponding sentence, Oto mayool hasuonra, as being a true description of the picture. Summing over the experimental results for this and all the other stimuli of the Association Experiment, while Hebrew speakers exhibit a 6.7% rate of acceptability of such alternative interpretations, reflecting a high degree of grammaticalization of thematic-role assignment, speakers of Abui exhibit a much greater readiness, at 71.8%, to accept interpretations involving alternative assignments of thematic roles, suggesting that the degree of grammaticalization of thematic-role assignment in Abui is substantially lower. Thus, the results of the Association Experiment in Hebrew and Abui dovetail nicely with those of the Context Experiment, both reflecting the greater degree of grammaticalization of thematic roles in Hebrew in comparison with Abui. Moreover, just like the Context Experiment, the Association Experiment reveals a clear and significant correlation with polity complexity, as per the scale in (3) above: in a sample of 69 different languages, including Hebrew and Abui, languages whose polities are of greater complexity exhibit a greater degree of grammaticalization of thematic-role assignment, again in accordance with the Complexity Covariance Hypothesis.The degree of grammaticalization of thematic roles is an abstract property of grammars that is manifest in a variety of ways, of which particular metaphor unidirectionality is just one. A more direct measure of the degree of grammaticalization of thematic roles is provided by the ongoing Association Experiment, some preliminary results of which have been published in Gil ,19 and GThus, appealing to the Evolutionary Inference Principle, the developmental journey from bidirectionality to unidirectionality in metaphors, argued for in this paper, may be viewed as part of a larger package, whereby the evolution of grammatical complexity and the grammaticalization of thematic roles, reflected also by particular metaphor directionality, are driven by the incremental increases in polity complexity that characterize the course of human prehistory.. 7Complexity Covariance Hypothesis, the positive correlation between complexity in the linguistic and the cultural and socio-political domains. Invoking the Evolutionary Inference Principle, such covariance points towards the reconstruction of an earlier metaphor bidirectionality, followed by an evolutionary journey from bidirectionality to unidirectionality.Although of a preliminary nature, involving just two languages, the results of the Context Experiment in Hebrew and Abui provide strong initial support for the In conjunction with previous studies mentioned earlier, the results of the Context Experiment support the existence of three stages in the evolutionary journey from bidirectionality to unidirectionality, with the third stage being further differentiated into earlier and later substages. These stages are represented in et al. [et al. [et al. [Stage 1, pure bidirectionality, is pre-linguistic: it is represented in rhesus monkeys by the space–time interference found by Merritt et al.  and the et al. . Stage 2et al. , Kogan e [et al. , Glucksb [et al.  and otheThus,