POVERTY AND HEALTH IN DEVELOPING COUNTRIES AND THE POTENTIAL ROLE OF TECHNICAL COOPERATION AMONG DEVELOPING COUNTRIES (TCDC) FOR THE POVERTY ALLEVIATION AND HEALTH DEVELOPMENT
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- POVERTY AND HEALTH IN DEVELOPING COUNTRIES AND THE POTENTIAL ROLE OF TECHNICAL COOPERATION AMONG DEVELOPING COUNTRIES (TCDC) FOR THE POVERTY ALLEVIATION AND HEALTH DEVELOPMENT
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"Macroeconomics,
Health and
Development" Series
Number 16
WORLD HEALTH ORGANIZATION,
Geneva, May 1995
Macroeconomics, Health and Development" Series, No. 16
Other titles in the "Macroeconomics. Health and Development" Series are:
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Macroeconomic Evolution and the Health Sector: Guinea. Country Paper - WHO/ICO/MESD. I
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Une methodologie pour le calcul des couts des soins de sante et leur recouvrement: Document technique.
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Debt for Health Swaps: A source of additional finance for the health system: Technical Paper WH0/IC0/MESD.3
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Macroeconomic Adjustment and Health: A survey: Technical Paper - WHO/1CO/MESD.4
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Planning and Implementing Health Insurance in Developing Countries: Guidelines and Case Studies:
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WHO/ICO/MESD. 10
and
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Paper-WHO/ICO/MESD.I I
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Guide pour la conduite d'un processus de Table ronde sectorielle sur la sante: Principes directeurs WHO/ICO/MESD. 13
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The public health sector in Mozambique: A post-war strategy for rehabilitation and sustained development:
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"......... ...
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POVERTY AND HEALTH IN DEVELOPING COUNTRIES
and the potential role of technical cooperation among developing
countries (TCDC) for poverty alleviation and health development.
CONTENTS
I.
Introduction
2.
Part 1.
2
Poverty and health in the poorest countries
- an inter-country comparison
4
3.
Part 2.
Strategic issues in managing poverty-health links
17
4.
Part 3.
Approaches to the health-poverty link and TCDC
26
5.
Part 4.
TCDC in poverty alleviation and health
- the scope and the action needed
32
INTRODUCTION
This paper focuses on the link between poverty and health. The link is
twofold: poor health retains the poor in poverty, and poverty keeps them in poor
health. One strategy for poverty alleviation is to direct special efforts at severing this
link and taking people out of the trap of ill-health and poverty.
Low income is often identified as the principal characteristic of poverty;
other forms of deprivation as derivatives of low income. This definition often tends
to simplify the processes that lead to and perpetuate poverty. Poverty, when broadly
defined as the lack of resources to satisfy basic needs, is multi-dimensional in
character. It is a condition which encompasses various forms of deprivation:
• inadequate income
• lack of education, knowledge and skill
• poor health status and lack of access to health care
• poor housing
• lack of access to safe water and sanitation
• insufficient food and nutrition
• lack of control over the reproductive process
While most often these exist together, deprivation in any one form acts
separately and independently as a determinant of poverty reinforcing the other
factors and perpetuating poverty. This is especially true of "poverty in health". The
health status is linked to all other variables. It is therefore necessary to identify
strategies by which health can act on the other variables.
The first part of this paper examines the situation in the 40 poorest countries
of the world. Four sets of health- related variables (approximately 25 in all) are
analysed, their relationships are examined for several groups of countries with
varying economic situations and some critical issues regarding the poverty-health
link are highlighted.
The second part examines in greater depth data for the poorest countries and
inter-country comparisons concerning the relationships between poverty and health.
It takes a subset of countries which have suffered negative rales of per capita growth
income in Africa and Latin America and examines health indicator and poverty
trends in these countries. It presents broad conclusions regarding the typical
problems and policy issues concerning health and poverty, drawing on relevant
experience from East and South East Asia, South Asia, Africa and Latin America.
The analysis in this section points to important areas where there is considerable
scope for sharing experience and lessons among developing countries.
In the third part, the potential for Technical Cooperation among Developing
Countries (TCDC) is analysed in greater detail, taking account of the unique
opportunity available in a situation where countries are at different stages of the
health transition. These situations enable a given country, on one hand, to transmit
the lessons of its own transition to the country lower down which is entering that
stage, and on another to benefit from the country in transitional stages immediately
above it.
2
The fourth part provides a selective survey of relevant initiatives and
experiences in TCDC. It examines the role of TCDC in areas of poverty alleviation
and health, briefly discusses existing mechanisms for TCDC and reviews the
progress made. There is an attempt to identify initiatives which have been
successful. The paper proceeds to outline the steps that should be taken to further
develop and strengthen TCDC in areas relating to poverty and health.
3
PART 1. POVERTY AND HEALTH IN THE POOREST COUNTRIES AN INTER-COUNTRY COMPARISON
ISSUES RELATING TO CROSS - COUNTRY COMPARISONS
It is possible to draw initial conclusions about how health indicators move
with reduction of poverty, by examining observable changes along the gradations of
income among the poorest countries in the world. Table 1 illustrates the 40 poorest
countries in terms of their per capita GNP, as listed in the World Bank's World
Development Report 1993. The countries have been grouped into four income
categories, the lowest income category with 11 countries having per capita incomes
ranging from US$ 80 (Mozambique), to USS 210 (Sierra Leone), to the highest with
10 countries having per capita incomes ranging from USS 500 (Sri Lanka), to
USS 650 (Zimbabwe).
Before the comparisons are examined, the limitations which are inherent in
such inter-country comparisons must be emphasized. First it is difficult to achieve
accurate cross-country comparability when estimating per capita GNP. The World
Bank's estimates which have been used in this paper have made adjustments to the
national GNP estimates after systematically assessing the appropriateness of official
exchange rates. Even after this is done the conversion does not adequately reflect
relative purchasing powers of currencies. The estimates computed on the
purchasing power parity of the dollar for different countries in the HDR, produce a
somewhat different ranking from that of per capita GNP in World Bank estimates.
Estimates based on purchasing power parity, also show a sharp reduction of
disparities between countries. Therefore the findings of this paper must be
considered as a broadly indicative analysis. The inter-country comparison and the
analytical framework need much greater refinement, but in their present form are
adequate for eliciting basic patterns in the relationships between poverty and health
and for analysing the main issues.
INDICATORS OF WELL-BEING AND THEIR SIMULTANEOUS UPWARD MOVEMENT
The 20 indicators that have been selected can be grouped in different
categories. One way is to group them into categories - health-related, educational,
demographic, food. Another is to group them as outputs and as inputs or processes
which are needed for the output. The output indicators will show the conditions of
well-being, such as life expectancy, infant and child mortality, adult literacy. The
indicators of the processes and inputs will include those that are health related, such
as access to health services (and within it pre-natal care), access to water and
sanitation, immunisation, the demographic inputs such as the fertility rate, birth rate,
population growth, the nutritional input in the form of the daily per capita calorie
supply, the educational inputs such as school enrolment and (within it) female
enrolment. The two categories of outputs and outcomes on the one hand and
processes and inputs on the other are not always mutually exclusive; school
enrolment is an input into the state of educational well-being and knowledge for
managing the adult life, but participation in education and the process of learning is
also a condition of well-being and personal fulfilment for the children of school
4
going age. Equally, low fertility is an input into health, but can also be taken as a
condition of well-being for both mothers and children.
Table 2 presents the mean of every indicator for each group of countries at
the four different income levels. Comparative data analysis available for the poorest
developing countries indicates that, for most countries health, reduction of poverty
and other socio-economic and demographic variables seem to be moving together.
Most of the important output indicators - income, life expectancy, adult literacy,
enrolment in primary schooling, fertility, daily calorie supply, and absolute poverty have improved simultaneously as countries move upwards from the lowest quartile.
The simultaneous improvement in these variables which can be observed in these
four groups of countries, has important implications for the links between poverty
alleviation and health. A first set of critical questions concerns the relative
importance of the income and other variables. To what extent is an upward
movement of the non income variables dependent on the upward movement of per
capita income, and to what extent is the dependence reversed? The crucial question
is whether the simultaneous upward movement of all key variables, income and non
income, is an imperative condition for the upward movement of each.
DEVIATIONS AND THEIR SIGNIFICANCE
The broad conclusions relating to the simultaneous upward movement of the
variables of well-being could be further developed and refined by examining the
trends at a more disaggregated level. Figure 7 attempts to plot the movement of the
variables at a more disaggregated level. An index of well-being (Table 4) was
developed to examine how the non-income variables have moved in relation to per
capita income. The methodology is explained in the annexed note (Annex 1).
Briefly, the index was compiled by assigning a score for each indicator at three
levels of achievement - low, middle, and high - and the sum of the scores achieved
by each country used as its score on the total index for the non-income variables.
The disaggregation points to certain important irregularities within the synchronous
movement observed for the all groups. These irregularities and exceptions could
provide us with a clearer understanding of critical variables that are at work.
Countries with a score below 35 are to be found in the three lower income groups;
countries between 35 and 45 in all four groups; between 45 and 55 in the second,
third and fourth groups; and the countries above 55 in third and fourth groups. The
non-income variables do not appear to move upwards invariably with income.
Nevertheless countries with the highest total index are in the highest two groups.
The irregularities emerge more clearly when selected key variables such as
life expectancy are tested against other variables. Countries with life expectancies
below 50 years are to be found in all four income groups. With the exception of
Bhutan, all these countries are in sub-Saharan Africa.
One set of indicators which does not fit into the general pattern is that of
nutritional data. Low birth weight can be found in Table 1. The percentages of low
birth weight for South Asian countries are much higher than for most sub-Saharan
countries which have lower per capita incomes, lower life expectancy, lower daily
calorie supply and much higher infant and maternal mortality. The obvious link
between poverty and malnutrition is the insufficiency of food consumption and
5
calorie intake. A high incidence of malnutrition disproportionate to levels of life
expectancy and absolute poverty appear to be characteristic of South Asian poverty.
Another related "deviation" is the per capita calorie intake; countries with low per
capita incomes, low life expectancy and high infant and child mortality report a per
capita calorie intake close to or above the norm, and higher than that of countries
with much higher life expectancy and lower infant mortality. The comparative
distribution of income does not provide an adequate answer. The explanation
appears to lie in some as yet unidentified variables, which may include, among
others, food behaviour, processes of physiological adaptation over long periods and
genetic factors. This raises questions about anthropometric norms being applied and
consequently the estimates of malnutrition.
There are individual countries in each group which deviate sharply from the
average in respect of one or more key variables. Madagascar, in the lowest quartile,
has an adult literacy rate far above that of any other country in its group. Sri Lanka,
in the highest quartile, has a percentage of low birth weight babies higher than that of
most countries in the lowest quartile, having much higher rates of infant mortality.
Nepal which has a higher illiteracy rate than many African countries has lower infant
mortality rates and enjoys a higher life expectancy.
THE RELATIONSHIP BETWEEN INCREASE OF INCOME AND IMPROVEMENT OF
HEALTH
While inter-country comparisons of the aggregate data per-capita GNP of
countries and their health-related indicators clearly show that increases in income are
most often accompanied by improvements in health, what is not equally clear is
whether this is an invariable outcome. In some cases increases in per capita income
are not translated into corresponding improvements in health. The health outcomes
can also vary widely among countries enjoying similar per-capita incomes. These
variations reflect the complexity of the relationship between health and income.
While health improvement and income increases interact closely, they seem to act
independently in response to other variables.
HEALTH CAN IMPROVE WITHOUT SIGNIFICANT INCREASES IN GDP GROWTH OR
PER CAPITA INCOMES.
In what special combination of conditions does this occur and when it does,
will the improvement in health lead to higher productivity and incomes thereby
acting on the health and poverty links to alleviate the poverty?
INCOMES CAN INCREASE WITHOUT IMPROVEMENTS IN HEALTH.
Whether health improves with increases in income will depend a great deal on how
the increment is allocated. For households, the allocation in relation to health will
depend mainly on patterns of consumption and health behaviour; while for
governments it will depend on priorities governing public expenditure. The
additional health expenditure will have very different health outcomes depending on
what expenditure is being incurred. The determinants of health are numerous, those
which are directly related to health, as well as those which act indirectly through
factors which influence health behaviour and affect the physical environment for
6
health. Part of the explanation for health outcomes variations at similar income
levels arises from the way in which health-related resources are allocated and
managed, whether at national or household level.
SYNERGIES AND IMPACTS OF HUMAN AND PHYSICAL CAPITAL
Deviations from the average pattern in each group draw attention to special
characteristics between these variables. The improvement in well-being appears to
be affected by processes at two levels. At one level the improvements in well-being
obtained through increases in income, life expectancy and health, education and
demographic changes appear to be interacting, producing a synergistic impact and
accumulating a fund of human capital which contributes to the simultaneous forward
movement of all key variables. At another level service inputs affect each condition
of well-being, such as access to health care, water and sanitation. This requires both
physical capital in the form of infrastructure on the community level and the capacity
of each household to access and use it. But the process does not always move
smoothly. Some elements may lag behind, whether they concern a condition of well
being such as income or literacy, or inputs such as access to health care. Even when
this happens, the fund of human and physical capital already created has an enduring
effect. It is often able to sustain the process of improvement even during periods of
lag in income growth or income decline. For example, when female education
improves it has an independent and continuing impact on child care, on household
expenditure, on childrens’ school enrolment on nutrition and so on, even during
periods of economic hardship.
It would seem, therefore, that when human capital is of a higher quality, it
can compensate for a lower level of service inputs. This is probably due to inbuilt
capacities at the household level which can be more effective than services delivered
by an external agency. In several countries with medium human development, as
defined by the UNDP Human Development Report , health personnel attend less
than 40% of births, which is also the mean for the countries with low human
development, yet their maternal mortality rate, ranging between 200 and 300, is far
below that of the latter where the average is between 600 and 700. These countries
with medium human development all have higher incomes, higher rates of adult
literacy including female literacy and higher daily calorie supply. With available
human capital, households in the medium range countries are not as dependent on
the external delivery of basic elements of health care, as are households in the low
range having much less human capital. This, however, does not mean that medium
range households have less access to general health care services than those in the
low range. Since the former would have more purchasing power and their countries
would have better health systems, a higher level of access is available.
7
Table 1 INDICATORS OF WELL-BEING FOR 40 POOREST COUNTRIES
No.
♦
1
?,
3
4
5
6
7
8
9
10
46
45
6.3
74
87
90
18
16
16
16
2.7
50
44
7.5
58
14
40
21
20
10
10
24
2
Tanzania
1
10
51
226
11
63
91
80
51
3
Ethiopia
1
12
48
861
13
38
71
46
28
Bhutan
1
18
48
131
13
26
6
Guinea-Bissau
1
18
39
175
14
59
97
7
Nepal
1
18
53
573
10
86
10
8
Burundi
1
21
48
585
10
72
85
20
6.0
16
73
29
25
24
12
46
5.5
10
73
9
13
15
26
45
6.8
12
81
80
17
17
14
11
70
31
9
41
2.4
39
47
5.9
80
39
25
39
2.0
45
47
42
8
27
2.5
38
56
48
52
2.9
46
57
69
30
10
Madagascar
1
21
51
101
11
92
63
65
20
11
Sierra Leone
1
21
42
178
14
48
86
37
50
12
Bangladesh
2
22
51
845
10
73
94
60
13
Lao PRD
2
22
50
151
10
10
11
67
37
33
2.6
44
46
5.9
21
21
22
18
21
5
81
2.8
43
45
6.2
62
34
77
14
16
10
62
24
2.6
48
45
6.5
25
69
30
22
25
13
32
37
1 9
34
48
4.4
7
69 _4Q_
13
2.9
44
45
6.7
34
13
24
36
16
15
14
21
23
3.1
53
45
7.6
59
88
76
52
2.3
42
43
6.4
28
86
82
17
18
23
36
3.1
50
45
7.0
27
45
11
19
21
71
12
20
3.0
47
45
6.5
33
46
49
18
19
12
55
10
31
3.5
52
44
7.4
47
28
33
19
21
20
15
50
1.8
30
50
3.9
33
90
70
10
13
30
50
43
71
3.5
45
43
6.5
28
62
11
85
15
72
50
15
52
2.8
44
45
5.9
45
43
86
14
15
17
90
83
97 _8Q_
1.3
22
56
2.4
94
94
7
35
6
4.7
20
30
43
13
12
15
14
Malawi
2
23
45
765
14
71
87
80
53
15
Rwanda
2
27
46
596
11
69
80
80
66
58
16
Mali
2
28
48
440
16
24
10
35
41
17
Burkina Faso
2
29
48
971
13
36
95
60
18
Niger
2
30
46
600
12
29
98
30
19
India
2
33
60
489
90
97
10
20
Kenya
2
34
59
800
67
94
86
77
21
Nigeria
2
34
52
198
85
72
93
22
China
3
37
69
38
13
11
94
17
7.3
12
53
63
43
619
94
85
52
47
125
3
3.3
21
55
19
51
1
37
86
31
Chad
3
77
18
15
9
Haiti
34
70
80
11
3.0
24
5
20
66
39
83
19
19
77
76
18
54
58
11
17
58
14
921
16
28
188
46
15
6.5
47
17
14
45
80
1
13
45
1
Uganda
12
29
Mozambiaue
4
11
24
1
23
|
Country
16
10 1
50
39
27
55
1.7
35
48
42
25
2.9
45
44
6.3
34
75
69
15
14
10
24
25
Benin
3
38
51
285
11
61
10
30
54
Central
3
39
47
447
10
67
77
30
12
21
40
2.5
42
46
5.8
66
52
38
17
17
18
26
Ghana
3
40
55
129
83
75
91
60
54
42
63
3.2
45
44
6.2
73
46
65
13
13
17
Country
Country
27
Pakistan
*
1
3
5
6
7
8
9
97
37
101
90
56
87
103
99
60
59
40
2
3
4
400
59
431
54
288
10
11
12
13
14
15
24
36 _Z.-.8
41
46
5.7
21
45
3.1
48
45
6.6
64
24
27
2.9
49
44
54
52
3.1
40
16
17
18
19
20
24
81
70
11
130
30
56
51
83
14
140
32
6.5
76
55
36
21
220
11
46
5.1
42
78
87
7
75
8
28
Togo
3
410
29
Guinea
3
460
44
500
136
37
100
30
Nicaragua
3
460
66
215
56
98
100
31
Sri Lanka
4
500
71
590
18
107
99
90
71
60
89
1.1
21
54
2.5
87
6
30
22
32
4
510
47
177
119
51
109
40
70
23
35
2.9
49
44
6.8
23
88
48
86
Mauritania
39
19
210
10
33
Yemen
4
520
52
347
109
22
93
30
68
41
3.7
52
44
7.5
11
50
17
14
175
10
34
Honduras
4
580
65
377
49
108
91
66
67
75
2.9
38
46
5.0
50
92
78
7
80
9
10
78
Lesotho
4
580
56
304
81
107
93
80
48
25
2.4
35
46
5.1
28
64
50
11
120
36
Indonesia
4
610
60
268
74
117
122
80
51
44
84
1.4
25
52
3.0
43
92
47
9
95
8
37
Egypt.Arab
4
610
61
190
59
98
133
99
88
51
50
2.1
32
48
4.2
24
90
40
9
80
12
38
Zimbabwe
4
650
60
630
48
117
94
S3
36
42
69
2.3
36
47
4.7
69
74
83
8
85
6
20
69
40
15
160
15
43
45
80
15
150
14
35
39
40
Sudan
4
51
145
101
49
83
60
45
70
28
3.0
44
45
6.3
Zambia
4
49
136
106
93
87
74
48
43
75
3.0
47
45
6.5
II.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Population growth rate/1991)
Crude birth rate per 1000 population/1991)
Women of childbearing age as % of all women/1991)
Total fertility rate/1991)
Births attended by health staff/1985)
One year old immunized/1992)
Pregnant women receiving pre-natal care/1990)
Crude death rate per 1000 population/1991)
Under 5 mortality/1992)
Low birth weight children per 1000 live births/1990)
Key to Indicators
* Groups according to GNP per capita. (1991)
1. GNP per capita.(1991)
2. Life expectancy at birth/1991) q
3. Population per physician/1970)
4. Infant mortality per 1000 live births/ 1991)
5. Percentage of age group enrolled in primary education/1990)
6. Daily calorie supply/1990)
7. Access to health facilities/1991)
8. Access to safe water/1991)
9. Access to sanitation/1991)
10. Adult literacy rate/1992)
o The data are for the year 1970. as comparable data for all countries were not available for a later year. This indicator needs to be updated.
Note:The data on GNP Per Capita are for the year 1991 from World Development Report 1993.
The data for other indicators have been taken from the Human Development Report 1994 and the World Development Reports 1993 & 1994.
Table 2 MEAN VALUES OF INDICATORS FOR EACH INCOME GROUPS
Remarks
Groups Mean Value
Variable Name
4
1
2
3
168.18
282.00
404.4
570.0
Poverty
47.27
50.50
55.55
59.60
Health
125.7273
111.90
89.77
69.625
Health
18.45
15.8
13.11
10.37
Health
157.72
169.3
131.66
109.37
Health
|| 6. Daily Calorie Supply
82.5
95.6
97.22
104.25
Food & Nutrition
|| 7. Low Birth Weight Babies
13.3
15.1
16.55
10.87
Food & Nutrition
| 8. Population Access to Health Services (%)
59.7
62.60
56.25
71.00
Access & Service
9. Population Access to Safe Water (%)
36.60
52.87
52.77
63.14
Access & Service
| 10. Population Access to Sanitation (%)
29.40
25.77
38.88
47.50
Access & Service
11. Births Attended by Health Personnel
31.7
34.11
53.88
41.87
Access & Service
12. One Year Old Immunized
61.09
58.10
62.44
74.73
Access & Service
13. Pregnant Women Receiving Prenatal Care
52.72
57.37
61.37
55.00
Access & Service
33925.45
39381.60
23008.75
15956.25
Access & Service
15. Percentage of Age Group Enrolled in Primary Education
61.36
66.90
74.60
90.87
Education
16. Adult Literacy Rate
42.44
43.62
46.39
63.28
Education
2.7
2.79
2.611
2.31
Demographic
18. Crude Birth Rate
45.09
44.10
40.77
36.60
Demographic
19. Women of Child Bearing Age
45.27
45.30
46.00
47.62
Demographic
20. Total Fertility Rate
6.40
6.23
5.47
4.85
Demographic
1. Gross National Product (US Dollars)
2. Life Expectancy (Years)
3. Infant Mortality Rate
|| 4. Crude Death Rate
|| 5. Under 5-Year Mortality Rate
14. Population per Physician
17. Average Annual Growth of Population
Figure 1
Selected Health Indicators
(mean values for the 4 country groups)
□
Group
1
4-
Group
2
O
Group
3
A
Gr o u p
4
Figure 2
- Selected Education Variables
(moan values for the 4 country groups)
□
Gr o u p
1
+
Group
2
O
Group
3
A
Gr ou p
4
Figure 3
Selected Access & Service Variables
□
Gr ou p
1
4-
Group
2
O
Group
9
a
Group
4
Figure 4
Selected Demographic Variables
□
Group
1
+
Group
2
O
Groups
A
Group
4
Figure 5
Selected Access & Service Variables
Ct r •
□
cn
Group
1
+
Group
2
O
Group
S
A
Group
4
Figure 6
Selected Food & Nutrition Variables
□
Gr o u p
1
+
Group
2
O
Groups
A
Group4
PART 2. STRATEGIC ISSUES IN MANAGING THE POVERTY-HEALTH
LINKS
Observing these variables at an aggregate level in any given year across
income levels may miss some of the complexities in the relationship between
poverty and health. These are more clearly revealed by the movement of relevant
indicators in groups of countries over a period of time. This section has therefore
selected two sets of data for further analysis. One relates to a group of countries
which have experienced negative rates of growth during the period 1980-92. The
other examines key variables in three groups of countries at three levels of life
expectancy - below 50 years, 50 to 60 years and above 60 years.
THE EXPERIENCE OF COUNTRIES WITH NEGATIVE GROWTH
Table 3 provides data for the 17 poorest countries and 6 middle-income
countries which experienced negative growth for the period 1980-1992. As might be
expected, the impact of negative growth on infant mortality and life expectancy has
been most severe on countries in the lowest income quartile. Among these too,
variations are revealing. In countries having the lowest mean per capita incomes,
negative growth rates meant an intensification of absolute poverty that was already
high prior to the downturn. Any further lowering of real incomes below this level of
absolute poverty has a serious adverse impact on the capacity for survival. Therefore
in countries in group 1 (Ethiopia, Niger, Mali, Central African Republic, Benin) the
infant mortality rate (IMR) has risen or moved downwards at rates not exceeding 1.2%.
Countries in group 2 have been able to sustain a decline in infant mortality
above 2%, and countries in group 3, higher than 3%. On the whole countries having
a combination of higher per capita incomes and higher rates of adult literacy,
particularly female literacy, have been able to cope better with the negative rates of
growth. This is illustrated in the performance of countries such as Nicaragua,
Zimbabwe and Honduras as well as middle-income countries.
Some poorer group 1 countries with the lowest per capita incomes - such as
Madagascar and Togo - which have negative growth rates of 2.4% and 1.8%
respectively, but relatively high rates of adult female literacy and female enrolment,
are also able to lower their rates of infant mortality much faster than those of
countries with similar levels of income, e.g., Mali, Benin and Rwanda. These had
negative growth rates of 2.7 %, 0.7% and 0.6% respectively, and lower rates of adult
female literacy. Negative growth rates for Uganda have not been estimated in the
World Development Report; but Uganda experienced a drastic decline in per capita
income in the 1970s and 1980s. The situation in Uganda is worse than in most of the
poorer countries with negative growth; its IMR rose from 109 in 1970 to about 122
in the early 1990s.
In all these cases the effect of available human capital appears to be
independent of factors relating to income. The variables which seem to be acting
17
independent of income needed to sustain the improvement in well-being, are
relatively high female literacy and decline in total fertility.
These findings reveal two sets of issues which must be addressed in dealing
with the poverty-health links. One concerns the definition and concept of poverty;
the other relates to the simultaneous movement of the of well-being variables.
POVERTY AS LACK OF HOMAN AND MATERIAL RESOURCES
Poverty is most often defined in terms of current income. The poor are
identified as those whose current incomes are insufficient to satisfy the minimum
nutritional requirements and other basic needs. The "current income" concept
assumes that low income will adequately reflect deprivation in all other forms. It is
indifferent to numerous other non-economic variables which in combination with
economic ones produce inadequate current incomes of the poor. Such an approach
concentrates on the economic dimension of poverty. It tends to neglect, first, the
central role of human capital in poverty and, second, the collective nature of poverty
in relation to social and economic infrastructure. The lack of human capital - low
levels of education and poor health - reduces income-earning capacity and
perpetuates poverty. This lack has to be seen, therefore, not as a derivative of
"income poverty", but as an independent aspect of poverty which contributes to it.
Poverty should be perceived holistically as an absence of “well-being" where poverty
of health, knowledge, education, environmental well-being and income are
elements of a total condition in which people lack an entire range of essential
resources, both human and material. A major part of any strategy for poverty
alleviation must focus on all those processes which improve human capital - health,
nutrition, knowledge, skills and literacy, both in terms of households and the
community.
These forms of deprivation also draw attention to another important
dimension of poverty. The condition of deprivation is one where poverty of
households is integrally linked to the collective poverty of communities. When
measured in terms of the household and the individual, poverty appears related to
their directly available resources. Households and individual poverty derives from
the collective or community poverty in which it exists. It results from an inadequate
economic and social infrastructure, lack of communal amenities for sanitation, water,
health care and education. Therefore the processes which alleviate poverty have to
be powerful enough to eliminate these collective elements. Their removal requires
strategies capable of distributing improvements equitably throughout society; it must
transform both backward parts of the economy and weak social infrastructures which
produce poverty.
THE SIGNIFICANCE OF SIMULTANEITY IN DEVELOPMENT
The manner in which all key variables move upwards together points to
"simultaneity" of the advance as a primary factor in improving well-being. Each
factor of well-being - income-related, health-related, educational and demographic
among others - seems to generate a system of supply and demand within which they
interact continuously. They tend to move towards equilibrium, in a manner
analogous to factors of production in the equilibrium model for an economy.
18
These variables relating to well-being are interdependent and interact
closely. In real situations there is always disequilibrium with one or more "factors"
of well-being lagging behind. Processes at work within the system of well-being as a
whole, as well as the internal momentum of each factor seem to move them
constantly towards an equilibrium.
A fuller understanding of these processes is therefore critically important for
policies relating to health and poverty alleviation. In certain situations some
variables appear to be triggers activating other variables such as female education or
nutritional intake. The "trigger" variables are different for different situations,
depending on the existing disequilibrium. These observations underscore the need
for an approach which identifies each of the key "output" variables. As integral parts
of total well-being, towards which each must move, the output variables concerned
are: health status, economic well-being (including income and income earning
assets), availability of shelter, water and sanitation, level of education, and
participation in the decision-making that affects well-being. The poverty-health link
should be defined and understood within that of total well-being. The policies
relating to each key variable should be planned in relation to the prevailing
disequilibrium. The annexed chart (Figure 8) attempts to depict the relationships
between the different resource bases needed for well-being, the processes which
produce or reduce poverty conceived as lack of well-being, and the outputs which
result in improvement, stagnation or loss of well-being. Each set of variables is
linked to the others by two-way relationships and by circular relationships. The
health-poverty link must be identified and managed within this system of
relationships.
The circuitous nature of the path to poverty alleviation and well-being will
vary significantly among countries. For several countries with high mortality, high
fertility and high female illiteracy, the path may lie through female education, better
spacing of births, smaller family size, better health of women and children. These
may result in an increase in the productive labour available to the household and a
new and higher income generating capacity. The path for countries, such as
Madagascar, with a high rale of literacy may be different. Sri Lanka, with its high
social indicators co-existing with poverty, unemployment and malnutrition, will
again require strategies which focus on that country's special constraints. The
framework which the paper develops can help plot such paths.
19
Table 3 INDICATORS OF WELL-BEING FOR COUNTRIES WITH NEGATIVE GNP PER CAPITA GROWTH
20
Country with negative
Annual rate of
GNP
% of age group enrolled in
Total
Infant Mortality
% Pop.
Life
Rate of
Rate of change
Lile exp. at
GNP per Capita growth
GNP
per
education - Female
Fertility
rate (per 1000 live
years
change in
in life exp. at
birth
rate
births)
in
absolut
lost(per
IMR
birth
in 1980-1992
Capita
USS
80-92
Mozambique
-0.1
-3.6
Ethiopia
1.4
-1.9
1970
1991
1970
1991
1970
1992
1970
1982
1992
60
*
53
*
5
6.7
6.5
156
105
162
110
10
21
2
11
5.8
7.5
158
122
122
1992
1000
people)
1992
1990
Secondary
Primary
60-80
e
poverty
70-82
82-92
70-82
82-92
70
82
92
Low Income Economies
58.9
141
-3.2
4.4
1.8
-1.5
41
51
44
60.0
107
-2.1
00
1.8
0.4
38
47
49
65.9*
188
-0.3
-2.8
-0.8
1.2
42
38
43
0.4
0.0
42
44
44
*
-1.4
160
27
39
5
12
6.5
6.5
197
190
143
Malawi
2.1
-0.1
210
*
60
*
3
7.8
1.7
193
137
134
81.5
110
-2.8
-0.2
Madagascar
-0.5
-2.4
230
82
91
9
18
6.6
6.1
181
116
93
43.4
63
-3.6
-2.2
1.1
0.6
42
48
51
0.0
42
46
46
Sierra Leone
Rwanda
1.5
■0.6
250
60
70
1
7
7.8
6.2
142
126
117
Niger
-1.6
-4.3
280
10
21
1
4
7.2
7.4
170
132
123
Mali
1.4
-2.7
310
15
19
2
5
6.5
7.1
204
132
Nigeria
4.1
-0.4
320
27
62
3
17
6.9
5.9
139
109
85.3
124
-1.0
-0.7
0.8
34.2*
121
-2.1
•0.7
1.4
0.2
38
45
46
130
54 1
108
-3.6
-0.2
1.2
0.6
39
45
48
84
40 0
98
-2.0
-2.6
1.3
0.4
43
50
52
55
58
67
Nicaragua
0.9
-5.3
340
81
104
17
46
6.9
4.4
106
86
56
Togo
3.0
-1.8
390
44
87
3
12
6.5
6.5
134
122
85
Benin
0.4
-0.7
410
22
39
3
7
6.9
6.2
155
117
110
20.0
29.6*
64.6*
45
-1.7
-4.2
0.5
1.4
79
-0.8
-3.5
0.9
1 6
42
47
89
-2.3
-0.6
1.1
0.6
42
48
90.1*
74
•13
-1.2
1.1
-2.1
-0.6
Central African Republic
0.9
•1.5
410
41
52
2
7
4.9
5.8
139
119
Ghana
-1.0
-0.1
450
54
69
8
29
6.7
6.1
III
86
81
41.9
55
Mauritania
1.6
-0.8
530
8
48
0
10
6.5
6.8
165
132
117
85.7*
♦
-1.8
Zimbabwe
0.7
-0.9
570
66
120
6
45
7.7
4.6
96
83
47
59.3*
37
Honduras
1.1
-0.3
580
87
107
13
34
7.2
4.9
110
83
49
36.4
Lesotho
6.1
-0.5
590
101
116
7
30
5.7
4.8
134
94
46
55.5
105
48
55 1
51
47 1
-0.2
42
1.7
0.2
45
55
56
-1.2
1.2
0.6
39
45
48
-1.2
-5.5
0.8
0.7
51
56
60
27
-2.3
-5.1
0.9
0.9
54
60
«
-2.9
-6.9
1.0
1.2
47
53
66 |
60 1
Lower Middle Income Economies
Cote d’Ivoire
2.5
-4.7
670
45
58
4
16
7.4
6.6
135
119
91
*
50
-1.0
-2.6
0.9
1.8
4
4
31
6.5
4.7
153
126
82
60.0
59
-1.6
-4.2
0.7
1.6
4
5
70°
6.0
* , 6.7
*
6.3
*
6.3
3.3
108
83
52
32.0
32
-2.2
-4.6
0.4
1.1
5
5
65
5.1
100
66
62
70.4
41
-3.4
-0.6
0.9
0.8
5
6
65
3.0
90
65
41
54.7
24
-2.7
-4.5
0.3
0.9
6
6
3.5
100
78
45
55.8
21
-2.0
-5.4
0.6
0.6
5
6
68
67 1
Bolivia
2.1
-1.5
680
62
81
20
Peru
1.1
-2.8
950
99
126
27
2.8
-1.5
980
51
73
100
96°
8
♦
95
*
■■
Guatemala
Dominican Rep.
Ecuador
3.4
4.5
-0.5
-0.3
1050
1070
23
Note : * Not available, ‘ % of Rural population in absolute poverty, 0 for the year 1990
Prospects
56 1
—
Source : World Development Report; Human Development Report; World Population
Table 4 TOTAL INDEX OF WELL-BEING EXCLUDING GNP PER CAPITA
!
Country
>
Number
Country Name
Total
Total
Total
Tola!
Demographic
Education
Nutrition
Index
Index
Index
Index
Index
1
Mozambique
16
5
7
5
33
2
Tanzania
26
5
8
5
44
3
Ethiopia
14
5
7
7
33
4
Uganda
23
4
9
7
43
5
Bhutan
18
8
7
7
40
6
Guinea-Bissau
18
8
7
6
39
7
Nepal
14
8
8
7
37
8
Burundi
27
4
8
5
44
9
Chad
12
6
6
5
29
10
Madagascar
19
6
15
7
47
11
Sierra Leone
18
5
7
5
35
12
Bangladesh
21
10
9
8
48
13
Lao PRD
18
5
15
8
46
14
Malawi
23
4
8
5
40
15
Rwanda
27
8
11
4
50
16
Mali
13
4
7
10
34
17
Burkina Faso
17
4
6
6
33
18
Niger
13
4
6
5
28
19
India
22
10
13
7
52
20
Kenya
22
5
15
5
47
21
Nigeria
18
6
13
5
42
22
China
27
10
15
10
62
23
Haiti
16
10
9
6
41
24
Benin
17
6
8
10
41
Central African
13
6
9
4
32
25
Republic
22
Total
Health
Country
Country Name
Number
Total
Total
Total
Total
Total
Health
Demographic
Education
Nutrition
Index
Index
Index
Index
Index
26
Ghana
17
5
13
4
39
27
Pakistan
26
6
7
7
46
28
Togo
21
4
1 1
5
41
29
Guinea
17
6
7
8
38
30
Nicaragua
25
7
12
10
54
31
Sri Lanka
30
10
15
5
60
32
Mauritania
16
4
7
10
37
33
Yemen
15
4
9
8
36
34
Honduras
28
8
12
8
56
35
Lesotho
19
10
15
8
52
36
Indonesia
24
10
15
10
59
37
Egypt. Arab Rep
28
10
13
8
59
38
Zimbabwe
23
10
15
8
56
23
Figure 7
COUNTRIES AND TOTAL INDEX
65
22
60
3~t
□ □
3 63 7
55
30
TOTAL
19
50
35
15
20
O
2
—
27
1 3
—....... .
8
4
21
40
U
u
5 0
14
2324
28
6
26
29
7
...........
35
32
-
1 1
... .
S3
1 6
13
17
25
30
9
18
25
1
| 3
| 5
| 7
| 8
2
4
6
8
| 1 1 |13 | 15 | 17 | 19 | 21 |23 | 25 | 27 |29 |31 |S3 | 35 |37 |
1 0
1 2
1 4
1 8
1 8
20
22
COUNTRY NUMBERS
24
26
28
30
32
34
38
3 8
INDEX VALUES
1 2
10
45
Figure 8
THE PROCESS OF INTERACTION IN ACHEVING WELL-BEING
PART 3. APPROACHES TO THE HEALTH-POVERTY LINK AND TCDC
The experience of countries in different development situations discussed
above, provides valuable lessons and a stock of appropriate knowledge offering
scope for a wide-ranging TCDC programmes on integrating health into poverty
alleviation.
THE RELEVANCE OF THE STRATEGY OF HEALTH FOR ALL TO POVERTY
ALLEVIATION
Already the WHO strategy of Health for All based on primary health care
contains many essential ingredients of "simultaneity". In focusing on basic health
needs, its central concern is with poor and groups at risk. From its inception, the
programme recognized the multi-sectoral nature of the effort needed for the
protection and improvement of health. Many sectors had to co-operate in the
strategy and programme for primary health care - agriculture, industry, education,
water and sanitation. Initially the multi-sectoral effort was organized specifically as
components of primary health care and around specific health care objectives.
The experience of the primary health care programme has, however,
revealed the complex nature of the interdependence between health and other
development processes. Just as health became a pre-condition for developing other
sectors, these became pre-conditions for developing of health.
Rather than
approaching other sectors for contributions to health, it had to be perceived as part of
an effort to improve the total well-being. This has implied a qualitative change in
approaching to health strategies. WHO and the member countries have been able to
develop wide-ranging programmes whereby improving of the health is integrated
into a total development effort for improving the well-being of the poor and
disadvantaged.
Innovative programmes at regional and national levels have built health into
composite programmes whereby an increase in income earning capacity and a
propensity to save, education and skill development, water and sanitation and the
sustainable use and protection of ecological resources are linked to health. These
programmes focus on the multi-dimensional character of poverty and the effort
directed at any single determinant is undertaken as part of a composite and
indivisible whole. A strategy aimed at eradicating poverty would need to incorporate
the positive experience of these programmes and build systematically on the links
between health improvement, economic advancement and other components of well
being. Table 5 includes a selective list of such programmes, which may be found in
all parts of the world.
SOME CRITICAL ELEMENTS IN STRATEGIES FOR POVERTY REDUCTION
Several important elements can be highlighted in the strategies which have
been relatively successful integrating health with the reduction of poverty.
26
DEVELOPMENT STRATEGIES AND POLICIES AT THE MACRO LEVEL
Development strategies and policies at the macro level are decisive in setting
the pace for the simultaneous advancement of all key variables that produce well
being. Among these the strategies that have been followed by East Asian countries
have been remarkably successful in achieving a combination of economic and human
development. These were at first broad-based, and in relative terms more equityoriented than most development strategies. Besides investing in economic growth,
substantial public and private resources were devoted to the developing human
capital through health and education. Developing an internationally competitive
economy was the main driving force. Through broad-based development, all
segments were able to participate in the expanding market economy and access to
markets became the key to growth of incomes and reduction of poverty. This mix of
policies resulted in a rapid reduction of poverty and improvement in health,
knowledge and skills of the people as a whole.
While this combination of policies and strategies has its roots in the socio
economic and cultural context of these countries and cannot be replicated in identical
manner in other developing countries, there is much that these countries, at lower
levels of well-being, could learn from the East Asian experience.
PROTECTING SOCIAL SECTORS AND THE POOR DURING ECONOMIC
RESTRUCTURING
Although access to markets can be a decisive factor in poverty alleviation,
many countries have experienced either stagnation or decline in the well-being of the
poor when they attempted to restructure their economies from state controlled
regimes to more liberal market-oriented ones. Others have been more successful in
designing policies which protected the poorer segments and sustained investment in
human capital, while carrying forward restructuring successfully. In the early stages
of liberalization and restructuring, several countries such as Sri Lanka, Ghana and
Mexico, among others, have implemented strategies with special interventions for
protecting and improving the well-being of the poor. One mechanism frequently
used in Latin American countries is Social Investment Funds. There have been
attempts by many international organizations, including the WHO, to bring together
available experiences for a more informed appraisal and to identify elements of
success which can be incorporated into national policies. These, however, are often
provided as prescriptions of international agencies. What is needed is a much more
intensive exchange and collective evaluation of their experiences by the developing
countries themselves.
MANAGING THE CRITICAL DEMOGRAPHIC VARIABLES
The intercountry comparisons reveal
significant differences in the
demographic situations of poorer countries. Nine countries which score high (above
fifty) on the total index appear to have made further progress from a situation where
both fertility and infant mortality are high, to one in which both are declining.
Appearing to be at higher levels of total well-being are several countries which have
been able to combine population policies aimed at reducing the natural increase of
population with the expansion of primary education to include females and access to
health care. This applies especially to primary health care including pre-natal care
and immunization of children. The equity-oriented and broad-based development
strategy would, therefore, need to pay special attention to these policy elements if it
27
is to have a significant impact on the reduction of poverty. Many of the policy
combinations and methods of implementation developed by the nine countries which
have fared well in terms of these policy criteria, could have great relevance for the
countries at lower stages of the demographic transition.
INTERVENTIONS TO ALLEVIATE POVERTY
Many countries have found that a broad-based strategy of development,
which combines rapid growth with human resources development through expansion
of primary education and primary health care, does not by itself enable the poor to
move out of their poverty at a pace that is needed. The East Asian examples of
South Korea and Taiwan are not entirely relevant to many societies where the
structural inequalities are high. The East Asian economies had the initial advantage
of radical reforms in land ownership which created an equitable base for the market
economy. Therefore, several countries facing structural poverty of a high order have
attempted to implement programmes of poverty alleviation especially targeted at the
poor. These range from national programmes such as the Janasaviya programme in
Sri Lanka to basic minimum needs programmes in the Eastern Mediterranean region
of WHO, similar ones in Thailand and a wide range of credit to the poor programmes
such as the Grameen Bank of Bangladesh and the Kupedes programme in Indonesia.
The programmes appearing to be most successful are those able to deal
simultaneously with all the major conditions of deprivation - low income, poor
health, high fertility, and illiteracy, especially female illiteracy. In most of these
programmes the poverty-health link is clearly articulated and dealt with. In extreme
poverty in which about a billion people live, health becomes a problem of survival.
Therefore protecting the health of the extreme poor is an absolute pre-condition for
all other efforts towards improving their well-being and alleviating poverty. High
infant and child mortality, undemutrition of all age groups, prevalence of
communicable diseases aggravated by a poor, insanitary environment, poor
reproductive health and large families, the especially disadvantaged situation of
women, heightened exposure to epidemics and natural disasters make up the familiar
health profile of the poor.
The poorer segments of the population are those who are most exposed to
risks of major diseases such as malaria, schistosomiasis and onchocerciasis. This is
partly because the regions where these diseases are endemic are also the habitats of
the poor. They are relatively neglected in the national allocation of development
resources and continue in the vicious circle of poverty. The HIV/AIDS pandemic is
likely to have its most damaging effects on the poor in regions such as sub-Saharan
Africa and Asia. How countries manage control and eradication programmes for
major diseases will have a significant impact on poverty and employment creation.
This has already been demonstrated by the way countries have benefited from
effective control programmes of malaria, schistosomiasis and onchocerciasis.
Various studies on the socio-economic environment of ill-health have shown
clearly that discernible variations in ill-health are related to seasonal climatic
changes. The rural poor are exposed to various health risks which are intensified
during the rainy season. In the dry zone in particular, it is between harvests when
stocks of food and income are low. Several elements combine to aggravate the
28
negative effects of the link between ill-health and poverty. There is a demand for
harder physical labour as preparation for cultivation commences. The nutritional
intake should be greater than at other times. These needs arise, however, at a time
when income from the last harvest is dwindling and standards of household
consumption are declining. The poor quality of the available shelter intensifies the
health risks in the rainy season. Sources of drinking water which are often not
protected are exposed to a high degree of contamination; faecal pollution from
unsatisfactory toilet facilities is worst during the rainy season. Higher incidence of
ill-health as a result of all these factors leads to a loss of working days and greater
demand for health services which are not easily available and involves costs even in
the case of free services provided by the State. In poor households the capacity to
cope with recurring seasonal stresses of this nature is critical to the condition of well
being. These episodic crises can create the vicious circle of ill-health and poverty in
which health intervention plays a strategic role. Health strategies integrated with
poverty alleviation should, therefore, pay special attention to the seasonal aspect of
health and its multi-sectoral character.
The targeted poverty alleviation programmes lead to two important
conclusions. First, the most revealing indicators of poverty are those which are
related to health status; they are indicators of the capacity for survival and the
maintenance of a minimum quality of life that is essential. Second, strategies of
poverty alleviation, to be effective, must give a central place to the protection and
improvement of health.
HEALTH AS A CATALYST IN PARTICIPATORY DEVELOPMENT
Successful poverty alleviation programmes show that poverty is most
successfully alleviated only when the poor acquire the capacity to participate in their
own development. Here again there is a wide variety of experiences relating to
participatory development and poverty alleviation. In most of these the initiatives
that can be taken by communities and households in dealing with their health
problems can act as catalysts for mobilizing the community. For a variety of reasons
such as parental involvement in child care and readily perceived benefits to the
community, these initiatives play a critical role in stimulating a process of
participation by communities and households. They lead to the empowerment of
women through all the elements of primary health care and become a major factor
for social and economic transformation. Setting community health goals can
transcend the parochial divisions and work as a unifying factor for mobilizing the
community to collective action which can then encompass other sectors.
This was demonstrated by the way the health component of the Janasaviya
programme in Sri lanka was conceived and implemented. The Janasaviya Trust
Fund (JTF), which is the main financing institution linked to the Janasaviya
Programme, integrates five components in its poverty alleviation programme - the
social mobilization of communities which encourages them to develop and move out
of poverty, the development of the economic infrastructure of poor communities, a
public works programme to absorb unemployed youth, a nutrition and human
resource development programme to improve the health and physical well-being of
vulnerable groups and a micro-enterprise development programme to promote
income-generating self-employment. The philosophy of the JTF recognises the
29
multi-dimensional aspects of poverty and the need to act on them simultaneously. In
another initiative, the Ministry of Health collaborated with the Janasaviya
programme in an effort to integrate the health component with poverty alleviation.
The programme called the Suvasaviya - the health version of the
Janasaviya - added several elements to primary health care programmes at the micro
level. These included community-based information systems, local level
epidemiological surveillance systems, appropriate packages of health education
material and systems for monitoring health care services which were designed and
implemented by the community.
In concept, Suvasaviya was effective for
mobilizing a community around well defined health goals and entering into the
larger programme for improving well-being. In implementation Suvasaviya was
limited to eight divisions and was therefore limited in its scope. Evaluation of the
programme indicates that some of its main objectives were successful. It was able to
encourage households to spend more on health improving investments such as
housing, water, sanitation and nutrition, thereby strengthening the foundation for
both improving and sustaining their well-being. Integrating health with poverty
alleviation in this manner sets in motion a process which enhances human capital of
households and communities and increases their ability to move out of poverty.
THE ALLOCATION OF HEALTH RESOURCES
In the entire effort of poverty alleviation, the allocation of health resources
plays a strategic part. In discussing the inter-country comparison in the first section
of this paper, it was argued that for health to improve with increases in income, the
increment in the income has to be allocated appropriately. There also has to be a
perception that the investment in health sustains the income-earning capacity and
helps to improve it. The allocative decisions at all levels - national, community and
household - must be such that they promote choices of lifestyle, patterns of
consumption and modes of behaviour conducive to healthy living.
At the household level, a poor household which has learnt to use its scarce
resources wisely on the main elements of preventive health - better food and
nutrition, a clean home, safe water, improved sanitation - will be healthier than a
household with a higher level of income, which neglects preventive health and
spends more heavily on curative care. The former has the resource base in health to
move out of poverty, the latter lacks that resource base and for this reason can lapse
into poverty. The health knowledge and behaviour which enable households to
manage scarce health-related resources might, therefore, be decisive in the
alleviation of poverty. The inter-country comparisons showed that this capacity, at
the household level, is created only through combining many processes where
female education plays a key role.
A major problem of poverty, insofar as it relates to health, is that most
households might not possess the capacity to provide themselves with the resource
base in primary household health. This lack inevitably moves them into sickness and
curative care which is costly in every way - loss of work, expenditure on medical
treatment - and consequently further aggravates their poverty. In these conditions
providing a basic infrastructure which improves access to health care becomes an
essential condition for breaking the vicious circle of poverty and ill-health. The
30
primary responsibility for health care of the poor lies with the State. In its effort at
poverty alleviation one of the first priorities of a poor country is to find ways and
means to finance an efficient public health care system which can be accessed by the
poor.
The criteria for resource allocation at the national level must take account of
the overriding importance of protecting health as the foundation for survival and
productive work in poor countries. The allocation for health must be in the nature of
a "preferential share" of the available public resources. The core resources for
health, and within this the minimum resources needed to sustain an effective system
of health care, should be clearly identified. There should be a firm national
commitment that this core will have the prior claim on available resources. The
inter-country comparisons show poor countries which have achieved a relatively
high level of access to health care, water and sanitation. Their experience in
developing a low-cost social infrastructure accessible to the poor will be of value to
other countries not yet able to do so. The Social Investment Funds of the Latin
American countries and programmes in the African countries such as Ghana, which
were mentioned earlier, have also been useful as instruments that "guarantee" a
reasonable level of resources to social sectors, especially during periods of structural
adjustment and consequent cuts on public expenditure.
But the perennial problem of poor countries is one of limited revenues which
impose severe constraints on public expenditures.
Within this context two
approaches are possible - one is the reallocation of available resources to strengthen
the primary health care system and those components which reach the largest
segment of the population. Such an equity-oriented allocation of resources will
inevitably benefit the poor. The other is supplementing State resources to the
greatest extent possible through mobilization of resources at the community level.
Health care systems would need to identify vulnerable groups and their
health needs, and realign both resource allocation and delivery to serve their needs.
It is important to identify countries which have attempted such exercises with some
success and make these experiences more widely available.
In mobilizing resources for health poor countries have been able to develop
many innovative programmes at the community level and savings at the household
level which can complement and strengthen resources made available by the State.
Cost recovery schemes which mobilize resources at the community level such as the
initiative taken by several countries, and now widely known as the Bamako
Initiative, is one such innovation. In different parts of the world there are several
similar schemes with elements of cost recovery providing an opportunity for pooling
knowledge on financing health care for the poor. The efforts to link credit to the
poor with programmes for health in Nigeria, the voluntary thrift and credit societies
in Sri Lanka and the experience of the Grameen Bank are a few examples among the
numerous initiatives taken to mobilize savings and promote investment in health.
They all offer lessons which can be shared.
PART 4. TCDC IN POVERTY ALLEVIATION AND HEALTH - THE SCOPE
AND ACTION NEEDED
The discussion in the foregoing section has shown that poor countries have
accumulated a considerable fund of experience and knowledge on poverty alleviation
which is available for systematic exchange among themselves in a programme of
TCDC.
AN OVERVIEW OF RECENT AND ONGOING INITIATIVES
After the programme of TCDC was formally launched in 1977, there were a
large number of initiatives taken by countries in the main regions of the developing
world - Asia, Latin America and Africa. TCDC, defined as the exchange of
knowledge, technology and expertise should be perceived in the larger context of
economic and other forms of cooperation among developing countries. A large part
of TCDC among developing countries has accompanied the expansion of trade and
investment flows, which have been increasing particularly from Asia and Latin
America. Technology transfers and management skills have accompanied these
flows. Along with TCDC in the economic sphere, there has been a considerable
effort to share experience in health, education and other areas of social development.
While the impact of several programmes has been significant, TCDC activities,
however, have still to build into a critical mass that could have its own independent
momentum for accelerating the development and improvement of well-being in
developing countries.
Several regional conferences promoted bilateral and multilateral TCDC
activities in the three regions. Some of the major initiatives undertaken through
TCDC having relevance for the issues of poverty and health include the following:
Food security schemes have been an important area of multi-country co
operation. These have been aimed at increasing regional food production and
availability; reducing post harvest losses; disseminating and improving processing
technology; providing early warning systems; reducing risks from natural and other
calamities. Initiatives have been taken in many regions including the Association of
South-East Asian Nations (ASEAN) and the South Asian Association for Regional
Cooperation (SAARC) regions of Asia and Sub-Saharan Africa. An example of such
an initiative is the Southern African Development Coordination Conference.
Security schemes of this type have been developed in the ASEAN and SAARC
schemes.
TCDC has promoted the sharing of technologies on a wide ranging basis
covering many sectors. The New Delhi conference in 1991 for example resulted in
400 exchange initiatives covering crop science, animal husbandry, fisheries,
horticulture, agricultural machinery, post harvest technology and dairy farming. In
all these areas there is scope for technology sharing appropriate to programmes
targeted at the poor. Examples are the bio-gas technology from China and India and
the exchange of food and agriculture technology including agreements between
countries within a region as well-as countries from different regions.
32
The following small sample of activities illustrates the type of activities
fostered by TCDC:
•
Argentina has cooperated with Nigeria to produce and promote use of
natural pesticides, and helped Nigerian producers improve the production
and marketing of potatoes and sunflowers.
o
Cuba provides expertise on molasses and use of sugar cane residues.
o
Peru assists Guatemala, Cuba and Colombia on an ancient Inca technique for
preserving potatoes with minimum loss of weight.
o
Argentina assists China to introduce cultivation of Yerbo Mate used to make
an infusion similar to tea.
o
Guatemala provides assistance to Argentina to control and eradicate cattle
worm and the African bee.
•
The chorker fish smoker which helps to preserve fish and enhance taste,
originating in Ghana, has been introduced into a number of other African
countries. Similar utensils which are cheap, easily produced and increase
the productivity of the poor, have been widely disseminated through TCDC.
•
Several institutions of a regional and interregional character as well as
national institutions with a regional reach have been established and have
strengthened the infrastructure for TCDC. These include the regional
centres for integrated rural development - CARDNE (Centre for Agrarian
Reform and Rural Development in the Near East), CIRDAP (Centre on
Integrated Rural Development for Asia and the Pacific), and CIRDAFRICA
(Centre for Integrated Rural Development for Africa). Another regional
institution which has relevance for transforming rural economies is the
regional Training Centre for Small Hydro-power in China. Mexico's
Institute of Electrical Research is an institution at the national level which
helps other developing countries introduce highly innovative energy
technologies - wind and solar energy and bio-mass micro-turbines. The
Wild Life Institute of India attempts to develop methods which reconcile
objectives of conservation with the development objectives of local
communities and has made its experience available to other countries.
There are a few other international institutions such as the International
Institute of Rural Reconstruction based in the Philippines and the network
of institutions under CGIAR (Consultative Group on International
Agricultural Research) which focus on issues of poverty, food and nutrition.
These can provide valuable technological support for TCDC initiatives.
•
TCDC initiatives which are more directly connected to the areas of poverty
alleviation and health include: ABREMEX, a programme of cooperation
between Argentina, Brazil, Mexico and Spain for promoting transfer of
technology and trade, including barter in the field of pharmaceuticals;
33
SOLIDARIAD the social programme which was initialed in Mexico and is
contributing to the poverty alleviation programmes of other Latin American
countries; the concept of the Grameen Bank which has found favour in
many other countries; the Social Investment Fund of Honduras, SEDESOL
of Nicaragua and similar programmes in El Salvador; the exchange of
experience and knowledge in primary health care among countries in the
Latin American region including harmonizing medical regulations, training,
exchange of products and establishing a technological information network.
THE POTENTIAL ROLE OF TCDC
TCDC initiatives already taken and institutional networks and mechanisms
already developed to promote it, provide a useful base on which a special effort of
TCDC could be organized and strengthened in poverty alleviation and health. TCDC
plays a unique role in social development, particularly in poverty alleviation and
improving the well-being of the poor. As discussed earlier, poor and middle-income
countries represent a gradation of development with examples of strategies, policies
and programmes appropriate to countries at different levels in this gradation. This
provides an effective framework for transmitting and exchanging experience
vertically, from one level to another, and horizontally, within levels, which can be
especially appropriate to the countries.
Table 5 attempts to assemble a sample of relevant initiatives undertaken in
poverty alleviation and health related areas by the four groups of poorest countries.
The table presents a matrix indicating the mix of countries in each group measured
on the index of well-being. It identifies a few selected initiatives and policy
approaches taken by countries in specific areas related to health and poverty. These
include: (a) macro-economic policies; (b) poverty alleviation measures including
income transfers, rural credit and employment generation; (c) the poverty-relevant
health strategies and programmes; (d) education in relation to poverty and health;
(e) water and sanitation programmes for the poor; (f) resource allocation for the
health of the poor. The matrix has been able to include only a small illustrative
sample of programmes under each category. It demonstrates, however, the rich
potential for an exchange on problems which is critical to countries as they move
upwards on the gradation of well-being. It should be noted that the coverage of the
matrix as presented is limited to the four income groups of the poorest 40 countries.
In any large scale effort at sharing relevant experiences on the poverty-health links, it
would be necessary to include those countries that have graduated to higher levels
such as Cuba, Costa Rica and others having a successful record in equity-oriented
strategies in Latin America, as well as the South-East and East Asian countries
indicated earlier in this paper.
THE CONTRIBUTION OF NGOs
One group of principal actors in TCDC are the NGOs in developing
countries which have been able to design and implement large-scale programmes in
poverty alleviation. Some of the NGOs have been listed in the matrix but these are
selective. Much more information is needed to compile a fuller list. These
organizations are repositories of a large body of appropriate knowledge and
technology, particularly strategies and programmes which have adopted integrated
34
approaches to poverty alleviation. They are, therefore, well equipped to become
effective partners in a wide- ranging programme of TCDC. International NGOs
from industrialized countries have worked closely with those of developing countries
and through their global operations can facilitate the flows of inter-regional and
regional TCDC.
A TCDC PROGRAMME ON ISSUES OF POVERTY AND HEALTH - ACTION NEEDED
The scale and nature of the TCDC programme that is envisaged would
require a sequence of actions:
o
First, it is essential to assemble all the relevant information of the type
included in the matrix and organize it into an information system which is
readily available.
o
Second, there is need for an in-depth critical evaluation of country
experiences, programmes and initiatives in the relevant fields in order to
develop the most effective elements of TCDC and guide and facilitate the
process.
•
Third, there must be a mechanism or mechanisms for the regular and
systematic flow of TCDC through exchange of experts for selected projects
and programmes, joint study missions between countries, joint training
programmes on specific issues and problems, workshops among groups of
countries having knowledge and experience for exchange on particular
issues, regional and inter-regional workshops and seminars.
•
Fourth, at the international level there should be an inter-agency programme
whereby participating agencies collaborate with developing countries to
design the programme and define each other's roles and participation.
•
Fifth, the TCDC programme focused on poverty and health would have to
build wherever possible, on existing TCDC activities and make maximum
use of institutions and networks which are already actively engaged in
TCDC.
•
Sixth, the programme must facilitate the sharing of experience, technology
and knowledge among NGOs in developing countries on a structured and
regular basis. This should form an integral part of the TCDC effort.
•
Seventh, inter-agency efforts should be re-oriented. One agency’s approach
to poverty alleviation may be through employment creation, another
through food and nutrition, another through education and adult and
functional literacy and another through health care. While each of these
make a specific contribution, their full synergistic impact can seldom be
realised unless they interact closely within a more integrated approach such
as the basic minimum needs programmes of WHO or the more successful
integrated rural development programmes.
35
The task of assembling, sytematizing and making available the body of
knowledge and expertise on poverty alleviation and improving the health of
the poor as an effective programme of TCDC, requires a collaborative effort
on a wide scale. This paper has attempted to show that the potential for
TCDC is quite large and when properly organized can have a critical impact
on enhancing the capacity of poor countries to alleviate poverty and
improve the well-being of the poor. The special focus of the paper,
however, has been on the rationale and need for integrating health
improvements with poverty alleviation. In the area relating to the poverty
health link, WHO, which is experienced in promoting cooperation among
developing countries would have to take the initiative and play the lead role
in strengthening and facilitating TCDC both at regional as well as inter
regional levels.
36
PROGRAMMES AND POLICIES RELATING TO POVERTY ALLEVIATION AND HEALTH
BY INCOME GROUPS OF POOREST COUNTRIES
Table 5
(1)
Per Capita
Income
US$
Group I
80-210
(2)
Scores for Indicators of
well-being other than
GNP Per Capita - Health,
Education, Demography,
Food & Nutrition, Social
Infrastructure
(3)
Macroeconomic
Policies for
Poverty
Alleviation
(4)
Poverty
Alleviation Income
Transfer, Rural
Credit,
Employment
generation
(5)
Heallh/Primary
Health Care,
Equity Oriented
Strategies
(6)
Education for
Poverty
Alleviation
(7)
Water/Sanitation
for Poor
Communities
(8)
Revenue Allocation for
Poverty Alleviation &
Health
4 countries at or below 35
Compensatory
Integrated rural
Primary health care
Strategies for
Rural water supply
Compensatory programmes
3 countries above 35 and at or
programmes to protect
development
programmes specially
enrolment in countries
projects
shown under 3
below 40
social sectors, during
programmes
those linked to female
with higher than
Inter-regional hand
education and family
averages for group -
pump project -
Community programmes for
planning
Madagascar
community waler
cost recovery and husbanding
supply schemes
of resources for health -
3 countries above 40 and at or
structural adjustment -
below 45
Madagascar among
Five country
1 country above 45
others
programme in sub
Saharan Africa for
(PHC/FE/FP)
Adult literacy, female
health, female literacy.
Six S movement PHC
programmes
income generation
Programme - West
Africa
African Bamako initiative
Five country
programme mention
Programmes for
under 3
control nature diseases
Group II
220 -
340
3 countries at or below 35
Similar programmes
Integrated rural
Similar programmes
Similar programmes
Similar programmes
Similar programmes (as
2 countries above 40 and at or
as given above
development
(as above)
(as above)
(as above)
above)
below 45
4 countries above 45 and at or
Rural Credit/ Grameen
Strategies for female
Orangi pilot project
Funds for poverty alleviation
below 50
Bank (Bangladesh)
enrolment -
Pakistan
programmes as in 3
1 country above 50
Nigerian peoples Bank
Bangladesh
Linking credit to health
Nigeria
Nutrition Programmes
(Tamilnadu)
Group III
460
370 -
1 country at or below 35
Similar programmes
Integrated rural
PHC/FE/FP
Enrolment strategies
Similar programmes
Low cost equity-oriented
2 countries above 35 and at or
as given above e.g.
development
programmes
for secondary
(as above)
health strategics - China
below 40
Nicaragua Ghana
programmes
Health and population
e.g. Ghana, Kenya.
Cost recovery schemes at
below 45
Strategics combining
Employment
strategics of countries
Nicaragua. China.
community level
India
3 countries above 40 and at or
education of females
1 country above 45 and al
equity with growth
guarantee schemes
with higher than
or below 50
e.g. China
Micro-Enterprise
average life
Social investment funds
1 country above 50 and at
Social security
development
expectancies for the
Nicaragua
or below 55
systems
Rural-Urban links
group - China.
1 country above 60
Nicaragua
(1)
Per Capita Income
USS
(2)
Scores Tor Indicators of
well-being other than
GNP Per Capita Health, Education,
Demography, Food &
Nutrition, Social
Infrastructure
(3)
Macro-Economic
Policies for
Poverty
Alleviation
(4)
Poverty
Alleviation
Income Transfer,
Rural Credit,
Employment
generation
(5)
Health/Primary
Health Care,
Equity Oriented
Strategies
Group IV 500-650
2 countries above 35 and
at or below 40
1 country above 50 and at
or below 55
Similar
compensatory
programmes (as
above) e.g.
Mauritania
Poverty alleviation
programmes e.g.
Food stamps,
Janasaviya in Sri
Lanka
PHC/FE/FP
programmes
Health
Social Investment
Funds e.g.
Honduras
Integrated rural
development
programmes
Social Security
Systems
Policies combining
equity with growth
e.g. Sri Lanka
Micro-enterprise
and small
enterprise
development
KIK/KMPK
Indonesia
Social sectors in a
market-oriented
economics e.g.
Indonesia
Rural-Urban links,
rural credit KUPDESIndonesia
5 countries above 55 and
at or below 60
Revolving loan
funds, Thrift and
Credit Society
(Sanasa) Sri Lanka
Foster father Business Partner
Linkages Indonesia
Population
strategies of
countries with
higher than
average life
expectancies for
the group - Sri
Lanka, Honduras
Programmes which
specifically link
with poverty
alleviation - Basic
minimum needs
programmes,
Suvasaviya of Sri
Lanka
(6)
Education for
Poverty
Alleviation
Enrolment
strategies for
secondary
education of
females e.g. Sri
Lanka. Egypt,
Zimbabwe
(7)
Water/Sanitation
for Poor
Communities
Similar
programmes (as
above)
(8)
Revenue Allocation
for Poverty
Alleviation &
Health
Low cost, equityoriented health
strategies Sri Lanka
Social investment
funds as in 2
Savings & thrift
linked to health
ANNEX 1
METHODOLOGY FOR COMPUTATION OF TOTAL INDEX
INDICATORS
RANGE OF VALUES (WEIGHTS)
DAILY CALORY SUPPLY
63-90(2)91-100(3) ABOVE 100(5)
ADULT LITERACY RATE
0-36 (2) 37-52 (3) ABOVE 52 (5)
POPULATION GROWTH
0-2.4 (5) 2.5-2.9 (3) ABOVE 2.9 (2)
TOTAL FERTILITY RATE
0-5.5 (5) 5.6-6.5 (3) ABOVE 6.5 (2)
POPULATION PER PHYSICIAN
1900-5000 (5) 5001-10000 (3) ABOVE 10000 (2)
INFANT MORTALITY RATE
18-70 (5) 70.1-110 (3) ABOVE 110(2)
POPULATION ACCESS TO HEALTH (%)
0-30 (2) 30.1-60 (3) ABOVE 60 (5)
POPULATION ACCESS TO SAFEWATER (%)
0-30 (2) 30.1-60 (3) ABOVE 60 (5)
POPULATION ACCESS TO SANITATION (%)
0-30 (2) 30.1 -60 (3) ABOVE 60 (5)
ONE YEAR OLD IMMUNIZED (%)
0-30 (2) 30.1 -60 (3) ABOVE 60 (5)
PREGNANT WOMEN RECEIVING PRENATAL CARE
0-39 (3) 40-72 (3) ABOVE 72 (5)
LOW BIRTH WEIGHT BABIES
0-10(5) 11-15 (3) ABOVE 15(2)
FEMALE % OF AGE GROUP ENROLLED IN EDUCATION (PRIMARY)
0-42 (2) 43-68 (3) ABOVE 68 (5)
FEMALE % OF AGE GROUP ENROLLED IN EDUCATION (SECONDARY)
0-5 (2) 6-13 (3) ABOVE 13(5)
VARIABLES CONSIDERED FOR HEALTH INDEX
VARIABLES CONSIDERED FOR DEMOGRAPHIC INDEX
POPULATION ACCESS TO HEALTH (%)
POPULATION ACCESS TO SAFEWATER (%)
POPULATION ACCESS TO SANITATION (%)
POPULATION PER PHYSICIAN
PREGNANT WOMEN RECEIVING PRENATAL CARE (%)
ONE YEAR OLD IMMUNIZED (%)
INFANT MORTALITY RATE PER 1000 LIVE BIRTHS
POPULATION GROWTH RATE
TOTAL FERTILITY RATE
VARIABLES CONSIDERED FOR EDUCATION INDEX
VARIABLES CONSIDERED FOR NUTRITION INDEX
ADULT LITERACY RATE
FEMALE % OF AGE GROUP ENROLLED IN EDUCATION (PRIMARY)
FEMALE % OF AGE GROUP ENROLLED IN EDUCATION (SECONDARY)
DAILY CALORY SUPPLY
LOW BIRTH WEIGHT BABIES PER 1000 LIVE BIRTHS
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