POVERTY AND HEALTH : WHO LIVES, WHO DIES, WHO CARES ?
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CONTENTS
SECTION I: SOCIAL AND ECONOMIC ASPECTS OF INCREASING POVERTY :
A GLOBAL PERSPECTIVE
1.
2.
3.
4.
5.
6.
7.
8.
Introduction................................................................................................................ 1
Why focus on poverty? .............................................................................................. 2
Defining poverty ........................................................................................................ 3
Analysing poverty - who defines what? .................................................................... 4
4.1 Micro level........................................................................................................ 4
4.2 Intermediate level.............................................................................................. 7
4.3 Macro level........................................................................................................ 7
Global health indicators developments ..................................................................... 8
Global developments affecting poverty and health ................................................. 9
6.1 Globalization ofthe world economy ................................................................ 9
6.2 Increased violence and conflict ......................................................................10
6.3 Poverty and environment................................................................................ 10
6.4 Demographic changes .................................................................................... 10
Changes within the health sector as a result of global developments..................... 11
7.1 The debt crisis and structural adjustment ..................................................... 11
7.2 Impact of user fees on utilization ofhealth services by the poor................. 12
7.3 Decentralization ............................................................................................ 13
Influence of poverty and ill-health on the household and
coping strategies of poor people ............................................................................. 14
SECTION II: THE PLACE OF HEALTH IN REDUCING POVERTY
9.
10.
11.
12.
13.
Poverty eradication as part of the overall development goal................................... 19
Poverty reduction through improved health ........................................................... 19
10.1 Land reform ................................................................................................. 20
10.2 Policies for increasing the economic asset-base of the poor: credit schemes . 20
10.3 Promotion of education - investing in women.............................................. 21
10.4 Poverty alleviation programmes and targeting the poor ............................ 21
10.5 The participatory approach - partnerships with NGOs and
civil society organizations and community groups................................................. 22
Health sector involvement in the eradication of poverty :
an option or an imperative?...................................................................................... 23
Summarizing the interaction between poverty and the health care establishment . 23
Poverty eradication and Health For All ................................................................. 25
SECTION I : SOCIAL AND ECONOMIC ASPECTS OF INCREASING
POVERTY - A GLOBAL PERSPECTIVE
1.
Introduction
There is broad agreement today that good health is a prerequisite for human development and
for maintaining peace and security, without which national economies cannot thrive. However,
there is no doubt that the main threat to health development today is poverty. In spite of dramatic
global economic growth, a quarter of the world’s population today is still affected by severe
poverty1 and the gaps between rich and poor are widening. Poverty not only increases the risk
of ill-health and vulnerability of people, it also has serious implications for the delivery of
effective health care such as reduced demand for services, lack of continuity or compliance in
medical treatment, and increased transmission of infectious diseases. Poverty may lead to
inequities in access to health care which in turn has implications both for health service capacity
and costs which are reflected in, for example, higher rates of complications due to late arrival of
patients. At the same time, a lack of adequate free or low cost health services for those unable
to pay contributes to further impoverishment of the poor. Growing evidence suggests that healthrelated risk events may well be the first step towards permanent poverty.
Economic and social developments world-wide have led to a situation where the vision of health
for all based on a comprehensive approach to health development through primary health care
has given way to a health care model which is based on the market approach. This development
has overshadowed the multi-dimensional aspects of poverty. Emphasis has been concentrated on
managing the consequences of poverty rather than addressing the complex causal processes
which perpetuate poverty and ill-health. The challenge for health professionals, health systems
and health decision-makers in poverty eradication is twofold: to actively participate in the
creation of an informed, supportive and health enabling environment necessary for the pursuit
of health for all; and to develop national health systems which protect and improve the health
status of the poorest groups of their populations as an essential element in poverty eradication.
This can only be achieved if the health sector is willing to break out of its isolation and pursue
collaboration with other sectors and groups in society, and by promoting the integration of health
objectives into the respective policies and actions of all sectors.
The aim of this paper is to contribute towards the discussion on poverty and health and on the
role of the health sector in poverty eradication. It offers a brief introduction to some of the
dimensions of poverty and health by drawing from articles, publications, and studies undertaken
at country level. The first section considers some of the definitions of poverty and analyses
1
14.
15.
16.
Basic principles and strategies for health sector involvement.................................... 26
14.1 Equity in health care.......................................................................................... 26
14.1.1 Equity in access and health care financing.................................................26
14.1.2 Promoting gender equity............................................................................ 27
14.1.3 Protecting the health of household wage earners and producers ............. 28
14.2 Protecting the assets ofpoor people by adapting health services to their
needs ....................................................................................................................... 28
14.3 Acceptability and relevance................................................................................29
14.4 Participation of the poor in health development............................................. 30
14.5 Training of health professionals ..................................................................... 31
14.6 Information and data monitoring ..................................................................... 31
14.7 Intersectoral collaboration and partnerships in health.................................. 32
14.8 Strengthening ofMinistries of Health.............................................................. 33
14.9 But not without the non-poor....................................... 33
From principles to action................................................................................................ 34
Concluding remarks ...................................................................................................... 36
ii
poverty from a micro, intermediate and macro level. The relation between economic growth,
poverty and health will be explored within the framework of global developments. Lastly, the
influence which poverty and ill-health has on a household and the coping strategies developed
by the poor will be examined. The second section will explore possible responses by policy
makers. By first considering a range of interventions outside the health sector, such as land
reform, education, economic production, poverty alleviation programmes and partnerships,
emphasis is placed on the importance of efforts in all sectors to eradicate poverty. The health
sector however, does have a specific role to play and the following part of the paper will
therefore focus on its role in poverty eradication within the overall framework of Health for All.
The values embedded in the vision of health for all of social justice, health as an integral part of
human development and participation of people in decisions which affect their health and lives,
will be interpreted into basic principles and specific actions which flow from these principles and
which should be considered by the health sector. This includes consideration of issues such as
equity in health, acceptability and relevance of health services to the poor and participation of
the poor in health development. The section highlights the need of those involved in health to
recognize that poverty is about people, and about their choices and opportunities to participate
in the process which ultimately creates the conditions for a healthy life.
2.
Why focus on poverty?
Poverty worldwide is associated with poor health. It is the greatest single cause of ill-health and
disease in the world today. Doing something about poverty will therefore have implications for
the health of individuals, the health of nations and global health. It will contribute to the effective
use of scarce resources for health care and to the sustainability of health services. Poverty
eradication, based on intersectoral collaboration and on full involvement of the poor themselves,
will create the conditions necessary for the development of appropriate quality care at all levels
of the health system. Ultimately a focus on poverty is a challenge both to build consensus around
and affirm values and principles which should guide health development in the future and to take
specific action to make this a reality.
However, poverty is also a moral and ethical issue. Giving poverty priority is a recognition of,
and a response to, the immense suffering and injustice which still exist in all parts of the world
and which we know could be avoided. It is a recognition of the importance of reducing
differences in circumstances between people in a way that enables all people to develop and
realize their full potential and to participate, and contribute towards society.
Poverty eradication is also motivated by economic advantages. Poverty represents a waste of
human resources and talents which could be invested to the benefit of society, in long term
2
productivity and economic growth of the country. Poverty eradication which results in improved
health and increased productivity is a worthwhile investment - not a drain on the resources of
a country.
Furthermore, there is a social argument for giving poverty priority. Neglect of poverty has
socially de-stabilizing consequences and spill-over effects such as an increase in tensions and
conflicts, and in migration both between and within countries. Furthermore, the increase of
infectious diseases as a result of poverty ultimately increases risks for all societies. A renewed
international commitment to poverty reduction and health development is needed to increase
prosperity and human security both on a national and global level2.
3.
Defining poverty
It is important to recognize that there is at present no universal concept of poverty and that much
of the debate on poverty has developed from a “Western” perspective3. The way we describe or
understand poverty depends on the historical, cultural and socio economic context in which we
live. Any attempt to reduce poverty should therefore reflect and respect these dimensions.
Increased efforts are needed to include the contributions from the non-Westem thinking in order
to fully understand the conceptual variations and the implications this may have for the
eradication of poverty on a global level.
Just as the definition of health can range from personal well-being, collective harmony, or
wholeness, poverty can be defined from the perspective of the individual such as exclusion, lack
of resources and deprivation, or from a perspective which links poverty to stages in the national
economic development, or to the existence of a social and economic disequilibrium1. Variations
in the understanding of poverty is reflected in the range of terms used to describe “poor people”
and “poor areas” such as “backward”, “under served” or “at the periphery of development”. In
view of the above, any attempt to define poverty needs to be done cautiously, keeping in mind
possible bias which such a definition may represent.
The sense in which poverty is used for the purpose of this paper is based on the definition
proposed by Chambers (1995) which refers to " a lack of physical necessities, assets and income.
It includes more than being income-poor. Poverty can be distinguished from other forms of
deprivation such as physical weakness, isolation, vulnerability and powerlessness with which it
For an excellent overview of different concepts of poverty see Novak M 1996, Concepts of
poverty, in Oyen E et al, 1996. Poverty : A Global Review. Handbook on International Poverty
Research. Scandinavian University Press
3
interacts."4
4.
Analysing poverty - who defines what?
Analysing poverty and developing adequate indicators to measure poverty is a complex process
since there are so many aspects of poverty, which cannot be measured, such as participation in
decision-making or in community life, lack of security and threats to sustainability. As a result,
poverty measurements have often been restricted to the analysis of income or consumption.
Recognition of the limitations of only measuring the economic dimension of poverty has led to
the development by the UNDP, of a Human Poverty Index (HPI) which brings together different
features of deprivation in the quality of life, in order to measure the extent of poverty in a
community. The three indicators include longevity (% of people expected to die before the age
of 40), knowledge (% of adults who are illiterate) and decent standard ofliving (% of people with
access to health services and to safe water, and % of malnourished children under 5)5. The HPI
provides a measure of the incidence of human poverty in a country but cannot be used to
associate the incidence of poverty with a specific group or number of people2. Analysis of
poverty which seeks to understand the dimensions, causes and manifestations of poverty
therefore needs to take into consideration different levels of poverty.
4.1
Micro level
Poverty should be analysed at the micro level, at the level of a person or family in order to
identify those family members or entire families in a community who are the most vulnerable
and who are most in need.
As part of such a poverty analysis, Chambers6 suggests that professionals, researchers and
development agencies seriously need to question who defines poverty, how local people
themselves identify the poor and the poorest members in their society, what criteria of poverty
or deprivation they have and what their priorities are. Stronger emphasis and consideration of the
reality of poor people as experienced and expressed by themselves will offer insights essential
to poverty reduction efforts. Deprivation and disadvantage as experienced by poor people
themselves is bound to reflect diversity and although not a single list will include all the
variations, some of the experiences of poor people are summarized in the table below.
The limits of this paper do not allow for an in-depth consideration of the HPI and interested
readers are encouraged to read the Human Development Report 1997, UNDP for further
reference.
4
TABLE 1
Dimensions of deprivation
Poverty
Lack of physical necessities, assets and income
Social inferiority
Can be assigned, acquired or linked with age and life-cycle.
It can be socially defined as genetically inferior or disadvantaged,
including gender, caste, race and ethnic group, or defined by social
class/group or occupation.
Isolation
Being at the periphery or excluded.
It can include geographic isolation, exclusion from communication,
contacts and information, lack of access to social services and markets and
of social and economic support.
Physical weakness
Includes disability, sickness, pain and suffering as well as the effect this
has on other household members through reduced capacity to contribute to
the household livelihood.
Vulnerability
Defencelessness and exposure to external risks such as shocks and stress,
and lack of means to cope without damaging loss.
Seasonality
Includes seasonal dimensions of poverty such as adverse factors which
may coincide with rainy seasons including shortage of food, difficult
conditions for agricultural work, scarcity of money, high exposure to
infection, and diminished access to health services.
Powerlessness
Bargaining power of poor people is reduced by work insecurity and lack
of resources and income. Physical weakness and economic vulnerability
diminish their influence.
Humiliation
Poor people are often treated with a lack of respect which in turn may lead
to a lack of self-respect. Dependency and helplessness reinforce the
experience of humiliation.
Source: Adapted from Chambers 1995, Poverty and Livelihoods. Whose reality counts? P 19-20
Knowledge of these dimensions of deprivation is important for the understanding of the effect
of poverty on people's behaviour, choices and priorities.
Absolute and relative poverty
An analysis of poverty at a micro-level includes a consideration of the concepts of absolute and
relative poverty. Much of the debate around poverty and health has emphasized the correlation
between absolute poverty and ill-health. More recently however, the notion of relative poverty
is also being used to explain ill-health, in particular in developed countries.
The UNDP Human Development Report of 1997 states that “ absolute poverty refers to some
absolute standard of minimum requirement, while relative poverty refers to falling behind most
5
others in the community"7.
Examples of recent research concerning developed countries points to the importance of relative,
rather than absolute living standards. In developed countries, socioeconomic variations in health
have been found to relate both to social position and to material circumstances. In terms of
causality, studies suggest that the health disadvantage of the least well-off in society is more
closely associated with the direct and indirect psycho-social effects of their social position (i.e.,
people’s position in the socioeconomic hierarchy in relation to others) than with the
physiological effects of lower absolute material standards (e.g., inadequate housing and heating,
poor diets, and air pollution)8. A study which looked at income distribution and mortality in the
USA found a clear association between variations between States in inequality of income and
increased mortality. The study concludes that “these findings provide some support for the notion
that the size of the gap between the wealthy and less well-off - as distinct from the absolute
standard of living enjoyed by the poor- seem to matter in its own right. This finding in no way
diminishes the importance of measures to alleviate the burden of poverty. None the less, in an
affluent society such as the United States, reliance on trickle down policies may not be enough society must pay more attention to the growing gap between the rich and the poor.”9 Caution to
draw these final conclusions with regards to the impact of income distribution on average life
expectancy among rich countries is recommended by some authors such as Judge10 who
challenges the "predominantly monocausal" explanation of international variations in life
expectancy. Wilkinson" however, who also found income inequality to be the key determinant
of variation in average life expectancy at birth among developed countries explains this by
looking beyond income as such. He underlines the importance of income as a determinant and
indicator of other material factors and of factors such as sense of control, self-esteem, security,
status, exclusion and cohesion12. These factors are closely related to those identified by poor
people in Table 1 as important dimensions of poverty but since exclusion and lack of self-esteem
are difficult to measure, little research has been undertaken on the mechanisms of influence of
these factors on health.
The implications of relative poverty on the health of people in developing countries has received
little attention, but it would seem relevant to focus on this dimension as well as on absolute
poverty in particular if the findings of a study by Beck13 in West Bengal are widespread among
poor people in other parts of the world. Very poor people were asked what it was they valued
most, food or self-respect. The overwhelming majority interviewed said that they valued self-
respect highest and one person replied : "If I don't have self-respect, will food go into the
stomach?"14 Beck concluded that "despite their regular hunger, more poorest people in the study
villages felt it was more important to be treated with respect than gratify immediate needs"15.
Focus group discussions in Kenya showed that one of the most distressing situations created by
poverty was not being able to offer guests a meal and arrival of unexpected visitors created a
6
situation of humiliation rather than social fellowship16. Will this not affect people's health?
Consideration by health professionals and others involved in community health development of
the effect of these dimensions to poverty on mental and emotional health, may have far reaching
consequences for the type of health care offered.
4.2
Intermediate level
Poverty can also be examined at an intermediate level by assessing the situation of particular
groups and people in a society, identifying those who are hardest hit by poverty and exploring
possible causes for this. At a national level, it is important to recognize which groups are most
affected by poverty and to explore possible common determinants of their disadvantaged
position, including ethnic, religious, or political belonging or geographical distribution. At the
local level, significant differentiation exists within the poor community, irrespective of which
criteria are used to demarcate groups of poor people. Analysing poverty at an intermediate level
therefore helps to distinguish the moderate poor from the absolute poor, and to assess the size
of the groups.
4.3
Macro level
It is a well-known fact that low levels of education and poor health decrease people’s capacity
to work and earn an income, and this in turn perpetuates poverty. Furthermore, the degree of
poverty of individuals and households will also be determined by the context in which they live,
social stratification, social mobility and the extent to which they may benefit from existing social
and economic infrastructure17. The lack of social and economic infrastructure, such as roads,
transport, water and sanitation, health care facilities, and schools, may be the result of
underdevelopment or the malfunctioning of the socioeconomic situation leading to a situation
of want, limited participation and lack of resources. As such, poverty can be seen as the result
of processes and structures at a macro level.
However, it is also important to recognize that poverty is not only influenced by national
economic and social policy and development. It is also an international phenomenon influenced
by transnational events and developments which result in poverty- producing processes 1819 such
as the breakdown of economic, demographic, ecological, cultural and social systems. This may
lead to a situation of great insecurity or vulnerability for many people which intensifies the
situation of poverty. The process of globalization is increasing economic, political and social
interdependence and the national and global levels are therefore closely interconnected. The
place of national economies within the international economy will influence the extent of poverty
in the countries and the extent to which they are able to develop and implement social and health
policies to address poverty20.
7
TABLE 2
ANALYSING THE LEVELS OF POVERTY
Micro level
Analysis of the multiple dimensions of deprivation as experienced
and expressed by poor people themselves
Intermediate level
Identification of the most vulnerable and disadvantaged groups
Macro level
Analysis of poverty from an economic and political perspective at
national and international level.
5.
Global health indicators developments
During the last 25 years, an unprecedented expansion of the world economy has taken place.
Global health indicators such as life expectancy at birth or infant mortality indicate that
developing countries overall have made progress. However, while life expectancy increased in
developing countries by 16 years in the period of 1990-1994, from 46 to 62, about one-fifth of
the population is expected to die before the age of 40. Infant mortality in the same countries has
decreased from 150/ 1000 to 64 /1000 live births, but regional variations exist. Sub-Saharan
Africa has a rate of 100/1000, and South-east Asia 112/1000. This is three times that of Eastern
Asia and six times that of industrialized countries21.
Health indicators from the Least Developed Countries3 reveal global disparities. Maternal
mortality, an indicator of the low social status and neglect of women, is 471/100,000 in the
developing world, 15 times the rate in industrialized countries. The World Health Report 1996
clearly demonstrates that there has been a sharp re-emergence of infectious diseases from which
no country can escape or afford to ignore. The precarious overcrowded conditions in which most
of the poor are living is conducive to the spread of the infectious diseases resulting in a dramatic
increase in diseases such as tuberculosis, diphtheria, HIV/AIDS, and hepatitis B. Diseases such
as cholera which were geographically restricted are spreading to new regions and major diseases
such as malaria are making new comebacks in many parts of the world22. Added to this is the
problem of increasing resistance to available drugs due to poor compliance to treatment. The
impact of several infectious diseases on poverty is a two-way relationship between poverty and
illness. There is no doubt that for example AIDS, tuberculosis, acute and respiratory infections
3 The 1997 Human Development Report defines the least developed countries as “ those recognized by
the United Nations as low-income countries encountering long-term impediments to economic growth, particularly
low levels of human resource development and severe structural weaknesses.” p.237
8
are linked to poverty and poverty itself facilitates the transmission of these diseases. About 17
million people a year in developing countries die from curable infectious and parasitic diseases.
In addition to this, many countries are experiencing a dubble burden of disease due to an increase
also in non-communicable diseases. Despite improvements in the access of health care, 50% of
the population in sub-Saharan Africa do not have access to any form of public health care and
although 69% of the world’s population now have access to clean water, in numerical terms in
the developing world, nearly 800 million people lack access to health care and nearly 1.2 billion
lack access to safe water23.
The increasing pressures that disease places on the poor coupled with disabilitating effects of
disease, have devastating consequences for their health and social well-being and in many cases
leads to social and economic disintegration and further impoverishment. As a result, the socio
economic development of many countries is substantially threatened.
6.
Global developments affecting poverty and health
6.1 Globalization of the world economy
The process of globalization has led to increasing reliance on free market economy and rapid
improvements in communications. The “invisible hand” of the market mechanism is oriented
towards privatization and liberalization of trade and foreign investment regimes, adaptation of
national economic structures and strengthening of export capacity. While the process may bring
opportunities and possibilities of economic growth and poverty reduction to some regions such
as East Asia, the benefits are not evenly distributed in developing countries as a whole 24.
Large segments of the world’s population have been excluded, and they are currently suffering
deterioration, both in relative and absolute terms. The number of poor is increasing. Between
1987 and 1993, the number of the world’s poor rose from 1.23 billion to 1.31 billion25.
Who is most affected by poverty?
The dominant tendency in developing countries and transition countries is that the main pockets
of poverty are located in the remote rural areas, and amongst the urban poor. Amongst those
hardest hit by poverty are parents with no or little education, households headed by single
women, children, young people for whom there are no jobs, the self-employed engaged in smallscale trading, the elderly, people with disabilities, refugees and other displaced people. Women
represent 70% of the world’s poor6 and they have less education, longer working hours and
lower life expectancy than mem7. People in developed countries are not spared from poverty and
9
women and children of these countries are the most affected by poverty. Child poverty has
increased throughout the 80s and children are currently the largest age group in poverty28.
6.2
Increased violence and conflict
Deepening poverty is one of the main driving forces behind the steady rise in the number of
conflicts within national borders and which are creating an unprecedented number of refugees.
The poor, in particular women, are disproportionately represented among the victims of conflict
and millions of people are forced to live on the brink of survival, either displaced in their own
countries or as refugees in neighbouring, often poor countries. Conflict diverts limited resources
away from human development efforts and the vicious circle of poverty and violence is nurtured.
For years following war or conflict, the health of people is threatened by unexploded mines and
total deprivation. Even so called “peaceful” economic sanctions hit the poor hardest, as
experienced by Haiti where, during the period of sanctions, drinking water was cut off,
malnourishment soared and the cost of staple food rose sharply29.
6.3
Poverty and environment
About one half of the world’s poorest people live on marginal or fragile lands and there is an
intimate connection between environmental degradation, and poverty-related behaviour such as
the search for food or fuel, and migration.30 Degradation of the environment not only increases
the health risks for the poor and vulnerable but hinders sustainable development. In addition, the
health of people living on marginal land is often seriously neglected since health services seldom
reach these areas. The process of urbanization (in part a result of migration towards the cities,
due to low agricultural productivity and lack of income gaining opportunities in rural areas) is
also a major global environmental change which directly affects human health today31. The
urban areas in which the poor live and work generally have sub-standard housing, weak
infrastructure and lack sanitary installations. Moreover, industrial pollution and high traffic
density contribute to the increased vulnerability of the poor in these areas32.
6.4
Demographic changes
Demographic pressures may also affect the already precarious environmental situation of the
poorest populations. However, one way of coping with the stress and insecurity of poverty is to
have many children who can participate in the household responsibilities, such as fetching wood
and water as well as in earning income for the family. Rapid population growth weakens the
potential for savings. It reduces the resources for improving health and education and it puts
pressure on natural resources. It also weakens women’s health, equality and autonomy- because
women end up with reduced options for education and income-earning work”33.
10
7.
Changes within the health sector as a result of global developments
7.1
The debt crisis and structural adjustment
Increasing concern by people and institutions worldwide is being expressed regarding the effects
of the debt crisis on the health and well-being of individuals and societies as a whole.
Introduction of structural adjustment programmes (SAPs) was proposed by the World Bank and
IMF as a way to overcome the severe economic and financial crisis affecting most of the
developing world in the early 1980s. Many indebted developing countries implemented SAPs
which aimed at decreasing State spending and stabilizing the economy and reductions were made
in public spending, often within health and education. The impact on the health sector of reduced
public spending was dramatic in many countries. Where funds were reduced for physical
infrastructure, equipment, drugs, staff salaries and training, the functioning of the health services
in several countries came to be seriously threatened 34.
Another clear result of reduced public spending on health was an increase in Selective Primary
Health Care (SPHC), narrow cost-effective technological health interventions35. Although health
interventions such as oral rehydration therapy and immunization were designed to target specific
identified problems of poverty, evidence suggests that they have not been able to reach their
targets or to improve the health status of poor people and in particular that of children36. The
broad Primary Health Care goal of improving the health status of of all populations, especially
that of the most vulnerable groups, was overshadowed in the implementation of SPHC.
Caution to draw cause and effect conclusions about the relationship between health and economic
crisis is advised by Sahn37 who found in a study of 21 Sub-Saharan African countries, that there
seem to be no causal relationship between macro-economic adjustment and a decreasing
government sector. Genberg38 also cites a study of 5 Latin American countries which concludes
that there is not sufficient evidence to associate the increase in morbidity at a national level with
the economic crisis. However, it is important to note that although “on average” there may seem
to be no relationship, there may be one for specific groups such as the poor. This is clearly
demonstrated in the examples from Nigeria and Zimbabwe presented in the following section.
The extent to which the poor have become poorer depends on their place in the economy (the
sector in which they are working, the prices of the products of those sectors, changes in
government subsidies and transfers, changes in prices of popular consumer goods etc).
In the process of globalization, the introduction of market mechanisms into the provision of
health care was proposed as the way forward for countries facing economic difficulties39. Health
care reforms involving policy changes in financing strategies and in public sector organization
were widely implemented. The most important reforms involved cost sharing through the
11
introduction of user fees and decentralization of health care.
7.2
Impact of user fees on utilization of health services by the poor
In an attempt to counteract the decrease in public spending within the health sector, and with the
aim of generating funds for health services, cost-sharing such as user- fees or co-payment has
been introduced in a large number of countries.
Many case studies have analysed the impact on the demand for health care following the
introduction of user fees. Among the conclusions drawn from these studies, user fees or a price
increase in health care have a tendency to reinforce existing inequalities in access to health
services unless exemption policies are put in place to protect the poor. Those at highest risk, the
old and poor, are generally pushed out of the system40.
An example from Nigeria illustrates well the effects of user fees on maternal mortality. In
Nigeria, a recent survey suggests that introduction of user fees has deterred at-risk women from
seeking antenatal health care with the result that the number of emergencies being admitted
without prior care has increased. Many of the women are poor and already at high risk since
“poverty greatly amplifies every other high risk factor for maternal mortality and maternal
morbidity”41. The unbooked emergencies are high risk patients and they make up 70% of all
hospital maternal deaths, and a higher number of intra-uterine and perinatal deaths. The women
arrive late, when their lives are already in danger due to difficult labour, complications, and
coincidental disease. The late arrival increases operational risk, and for those who survive, the
recovery is slow, hospital stay is prolonged and treatment costs, both for the provider and the
beneficiary are substantially increased42.
The consequence of reduced government spending has also had high social and humanitarian
costs in Zimbabwe where maternal mortality increased from 101 in 1989 to 265 per /100.000 in
199243. In 1991 Zimbabwe introduced rigorous fee collection at public health services in order
to reduce the fiscal deficit. The cost-recovery programme had a clear negative impact on the
health of the many poor people who were no longer able to afford the costs. Visits to health
centres decreased, in particular to antenatal clinics. As in the case of Nigeria, the number of
births in the Harare Central Hospital to mothers with no antenatal care increased substantially,
from 1.6% to 8.8%. The perinatal mortality rates for these women is five times as high as for
those who attend antenatal care44. In view of the adverse effect of user fees on poor people,
Zimbabwe withdrew the cost-recovery programme from rural clinics in 1995.
It is important to note that reduction of demand for health care as a result of the introduction of
user fees may also be closely linked to the quality of services. Studies such as the study by
12
Litvick and Bodart45 in Cameroon have shown that if user fees are reinvested in improving the
quality of care (such as availability of drugs), the reduction of demand may be lower than
expected and in some cases demand may even increase.
Variations in results of impact of the introduction of user fees or other cost sharing methods on
access to health services, especially of poor people, highlights the importance of allowing for
many factors and conditions in the studies of impact of user fees before drawing conclusions.
One important element is the comparison of the situation of poor people and in particular the
poorest people, before any cost sharing, with that after the introduction of cost sharing. A second
element is the examination of the use of the user fees collected - whether they have been
reinvested to improve quality of care in the health services or if they have been transferred to the
Ministry of Finances to reduce the fiscal deficit.
The above examples from Nigeria and Zimbabwe highlight a very important aspect of poverty.
While reduction in health spending is introduced to save costs, poverty may reverse the savings.
The existing situation needs to be carefully evaluated by policy-makers before introducing
changes in the financing mechanisms of health care which may adversely affect the poor.
7.3
Decentralization
Since the early 1980s, decentralization has been associated with the principles of Primary Health
Care, and it has been seen as a way to improve equity in health, increase accountability, raise
responsiveness to local needs and improve access of the poor to public health services.
Decentralization remains however a political issue which is influenced by different
interpretations by social and political groups and bodies with contrasting interests46. Although
the potential of increased community participation in decision-making and planning is present,
its success depends on a range of factors, including leadership, the influencing power of the local
elite, decision-making process and central commitment to equity in health. Decentralization can
increase inequities in health if the central level does not establish the means of ensuring equitable
distribution of resources. Decentralization has also been combined with cost-sharing mechanisms
which, as the case of China illustrates, has not always led to an improvement in the health status
of the poor.
By the end of the 1970s, China had put in place a cooperative organization of rural health
financing (called cooperative medical systems -CMS) which covered roughly 95% of the
villages. The system involved community participation and cost sharing (small contributions
from farmers and subsidies from collective welfare funds) and gave farmers access to basic
health care47.
13
Market economy reforms were introduced in the early 1980s involving a shift away from
communal to a household production system. This resulted in increased production autonomy
for farmers, better access to markets, and greater opportunities for local and regional trade.
However, the shift to a household production system meant a decrease in revenue for the
cooperative medical system, and at the at the same time, the Government reduced financial
support for recunent health costs, following the introduction of user fees and liberated prices in
the medical sector. This led to a dramatic rise in prices, and in many places the RCMS (Rural
Cooperative Medical Systems) were unable to generate sufficient income to cover their costs.
This, combined with administrative and political obstacles, led to the collapse of the RCMS. In
turn, this resulted in a decrease in preventive and curative care, and an increase in some
infectious diseases. By 1993, RCMS covered only 10 percent of the population in 4.8% of the
country’s villages.
In view of these problems, steps have been taken to improve access to health care in the rural
areas and to re-establish different models of RCMS by adapting them to the economic reforms
and to the local economic situation.
The example of China illustrates clearly that when introducing change, every situation must be
considered in its own context, from the historic, cultural, political and socio-economic
perspective. It also draws attention to the changing role of the State, within financing and the
provision of health care, and to the need for greater government regulation and monitoring of
the protection of the most vulnerable in the process of economic growth.
8.
Influence of poverty and ill-health on the household and
coping strategies of poor people
The relation between poverty and household economy is of special importance to any discussion
of poverty and health and it is at this level that the synergistic link between poverty and health
is most tangible. Poverty undermines health, renders people more vulnerable, and reduces work
capacity and productivity, thus limiting opportunities of income-earning. Low income in turn
perpetuates poverty and poor health.
The household economy4 is determined by a range of assets which most commonly refer to
4A useful framework which analyses the basic features of a household economy has been developed by
Carrin and Politi. The family is considered the basic unit of analysis and is defined as a group of people
living together or closely connected, sharing their food and/or working formally or informally in a family
enterprise. Carrin G. And Politi C. 1997, Poverty and Health, an overview ofbasic linkages and public
policy measures. Technical briefing note, WHO Task Force on Health Economics, 1997
14
“capital, physical or financial, from which people can derive a future stream of income”48.
However, it is also important to include other assets, including intangible assets of a social,
personal and environmental nature. The effect of ill health on these assets may be a major
determinant for further impoverishment of poor people.
8.1
The main assets of poor people are their bodies49. In many parts of the world household
labour continues to be the most important input for food or subsistence production. The poorer
people are, the more they depend on being able to work and earn an income. Their ability to work
is determined at large by their physical capacity which puts a very high price on physical
disability. At the same time, the poorer people are, the more vulnerable they become, to sickness
and accidents due to malnourishment and poor resistance to disease which in turn leads to slow
recovery. Poor people also have less access to timely and effective treatment or prophylaxis and
in many countries, the lack of employment may also mean exclusion from access to health
services.
8.2
Economic assets include land, livestock, housing and financial capital (savings and
credit). Poor health is an economic burden to the poor and in many countries contributes to
substantial erosion of these economic assets.
A study in Bangladesh revealed that the hard core poor households (those who were in the lowest
two deciles) spent up to 7-10% of their income on private health expenses50. Poor people are also
extremely vulnerable to serious, unexpected health problems which may lead to a loss of income
and income-earning capacity. They may be forced to borrow money or sell the few assets they
may possess, including livestock or land, to cover the costs. This leaves them more vulnerable
and often indebted with little possibility of repaying the debt and in great danger of moving
further down the poverty spiral. The same study in Bangladesh found that “ health-hazard related
risk events explain on average 16% of the causes of deterioration along the poverty spiral
experienced by households during the 1990 - 1994 period. For non-poor households, which
slipped into hard core poverty, the share of health-related causes is as high as 21%. While such
slippage may originate in the random nature of events, for many of these households it may well
turn out to be a route to permanent poverty”51.
8.3 The health of the breadwinner is critical to the health of the household. Preventing or
curing his or her illness may also be vital to the state of nutrition of children. Findings from a
study in an urban slum in Khulna, Bangladesh revealed that there was a strong association
between loss of income due to illness and severe malnourishment in pre school children52. The
study found that there were two and a half times more likelihood that children were malnourished
in a household where an adult earner had been sick during the last month, than in households
where the breadwinner was not sick. Preventing adult sickness may therefore be the cheapest way
15
to prevent malnutrition in children. However, the problem of malnourishment is not limited to
children - closer studies of households with severely malnourished children and incapacitated
earners, reveals that in addition to the children, most of the other household members are
malnourished.
Chronic illness which strikes a household will have severe effects on the family income and in
many cases, chronically incapacitated households are the most indebted with consumption loans
which may reach 500% of the monthly income53. Attempts to increase the household income will
be made by entering women and children into the labour force. However, restricted economic
options available to poor uneducated women intensify the pressure on the male income earners
and on the situation of the household, since women will rarely be able to reach incomes
equivalent to those of men. In their struggle to survive and earn income, women and children
may be exposed to high health risks such as injury among working children or infections and
violence among women forced into prostitution.
A permanently disabling disease can lead to slow but sure impoverishment and destitution in
young developing households. This was revealed in a study in Guinea looking at the impact of
onchocerciasis (river blindness) on individuals, households and villages. The disease, which
affects to a large extent young men, puts severe constraints on the ability of the household to
sustain its viability, rendering the household more and more dependent on help from the
extended family and
others in the village54
(Box.l).
; The progression of disease may include the following:
i
; •
The example of river
blindness
clearly
demonstrates the link
between ill-health and
poverty and it also
the
■ •
of
considering the impact
of
disease
on
a
household level rather
than an individual level.
process
progression
i •
I •
I •
highlights
importance
The
I •
of
of
the
I •
I •
; •
j •
I •
i •
;
i
increased dependency ratios (ratio of number of consuming 1
household members to number of active producing I
household members)
decrease in nutritional and health status of all household |
members and increased vulnerability to other diseases
decreasing labour input
decreasing capacity to participate in traditional labour I
exchange system
decreasing area under cultivation
decreasing ability of household food production to feed ;
household members
;
increasing duration of food shortage
>
decreasing ability to undertake food shortage coping |
strategies
increasing expenditure on scarce household resources on |
health problems, in particular blindness
decreasing household viability
increasing stress and household disunity
increasing reliance on village welfare system and extended |
family
disease and subsequent
problems
for
the
Box 1: The path from ill-health to poverty - the example of river-blindness
16
household is in no way unique to river blindness and similar assessments could usefully be made
for other diseases in order to identify the social and economic dimensions of ill-health.
Death of family members, especially men, may determine the future survival of women in many
countries. Inheritance laws do not always protect the surviving widow and in many countries,
widows do not inherit from their husbands, as is the case of many widows in India. If a widow
has no surviving sons, her property can be seized by the family of the deceased husband leaving
her extremely vulnerable 55.
8.4
An important asset for most poor families and especially for the women is time. Women
suffer from the lack of time, due to their triple burden of caring for the family, taking care of
domestic responsibilities, and earning money. Ill-health can seriously deprive them of time.
Coping mechanisms include involving children in the day-to-day domestic duties or income
generation. But this may take them away from school or expose them to physical strain which
threatens their own health.
In studies of malnutrition in children, especially where there is a chronically sick earner,
maternal time and intense financial poverty were major constraints on child care and feeding. The
time which is needed to visit health services, to cover long distances to get there, and long
waiting times all prevent women from earning income and these time constraints contribute to
the non-attendance of children at nutrition centres of health services. Studies from Uganda,
Nigeria and Cote d’Ivoire show that people seeking medical care may spend between 2 to 8 hours
to get to the hospital or clinic56. The situation is particularly precarious for women who are heads
of households.
8.5
Social and political assets include relationships of trust and mutual concern such as
those which exist within the extended family, which can be drawn on in times of stress or crisis.
Such relationships reflect the social cohesion which exists in many poor communities and they
are at the base of a broad range of self-help activities organized by the poor collectively to cope
with the consequences of poverty.
However, these relationships of mutual concern and support can be threatened in times of
increased social tension, conflicts, or as a result of problems such as alcoholism that results from
a deep decline into poverty or loss of income. The breakdown of the extended family as a result
of war and of AIDS, where the responsible adult population is severely reduced, leaves orphans
or other family members in a particularly vulnerable situation. Chronic ill-health can also put a
strain on social relationships and lead to increased tensions in the family or community. Ill-health
poses a special problem for people living in slum areas in cities where traditional protective
social networks such as the extended family, do not exist to the same extent as in rural villages.
17
In these situations, a greater burden falls on the individual households, in particular on the
women.
As illustrated above, the loss of one asset can in many cases lead to loss of others. Loss of time
due to ill-health often results in a loss of income which in turn can put pressure on social
relationships and lead to increased violence. Studies show that women in Hungary, Mexico, the
Philippines and Zambia have found a clear link between an increase in violence and a decline in
men’s income 57. Emotional distress inevitably accompanies the financial distress.
The infinite variety of coping mechanisms put in place by the poor themselves to overcome the
consequences of poverty reflect “enormous creativity, strength and dynamism on a daily basis
to solve problems [...] Poor people have assets, in their own minds and bodies, in their social
institutions, in their values and cultures, in their detailed and sophisticated knowledge of their
own environment”58. Protecting these assets and strengthening them will be one of the key
factors of success in the eradication of poverty.
How can this be achieved ? The following sections will consider some of the strategies used to
overcome poverty in particular those which may be developed by the health sector.
18
SECTION II : THE PLACE OF HEALTH IN REDUCING POVERTY
9.
Poverty eradication as part of the overall development goal
In societies with clear policies on equality and democracy and where the overall goal of equity
is the improvement of all its population's health status, the chances of health development for the
poorest people will be higher. Experiences from countries with a historical commitment to health
as a social goal, and to equality as a political goal confirm this. Costa Rica, Sri Lanka and the
State of Kerala in India have achieved considerable improvements in the health status of the
population by a series of political, social and economic interventions in society as a whole,
actively involving communities in the process59. In Costa Rica, where health is considered an
"investment in the nation, a necessity for social vitality and economic progress.[....].progressive
health policies have increased the income of the poorest 10% of the population by more than
65%"60.
A redistribution of resources in favour of the poor has been an important element of the overall
development policy to improve health status61. Also in developed countries, social policies
seeking to redistribute income and reduce income inequalities will have a significant effect on
health inequalities. In countries such as Japan, where the income differentials between the highest
and the lowest income quintiles are decreasing, improvements in the health status of the
population as a whole can be noted62. In countries such as the UK and USA, where these income
differentials are increasing, less improvements in health status and wider inequalities in health
have been found63.
Although not all countries have a national political commitment to equity and poverty
eradication, many sectoral strategies have been put in place to reduce poverty.
10.
Poverty reduction through improved health
Some of the most effective strategies to strengthen poor people’s assets (in particular health), to
reduce poverty and to enhance the participation of poor people in social and economic activities,
have been undertaken outside the health sector. Examples of this have been amply described
elsewhere 64 and what follows is a brief summary of some of these strategies.
19
10.1
Land reform
A major cause of poverty today is unequitable distribution and ownership of land, which not only
contributes to rural poverty but also to the expansion of urban slum areas. Land reforms which
aim at a more equitable distribution of land and a more efficient use of the land, will contribute
substantially to poverty reduction. This is confirmed by the experiences from Japan, South Korea
and Taiwan where, as a result of land redistribution, farm output increased which in turn led to
increased income and saving and to a higher demand for domestic products65. In the State of
West Bengal in India, considerable social benefits have resulted from the introduction of
legislation to strengthen tenure laws, protect landless labourers and enhance the position of share
croppers66.
10.2
Policies for increasing the economic asset-base of the poor: credit schemes
Credit schemes enable the poor to sustain their level of consumption in difficult times, by
allowing them to pay for physical investments as well as services such as health care and
education67. In addition, they may offer poor people opportunities to participate in the labour
market or the production of goods, thus allowing them to create new assets from which to draw.
Successful examples of credit schemes can be found in all regions and they include for example
investments in income generating activities for women in Bangladesh, farming co-operatives in
Zimbabwe68 or housing initiatives in The Gambia and Antigua69. One of the most well-known
credit scheme is the Grameen Bank in Bangladesh which since 1983 has been giving credit to
the landless and to poor women. The scheme has currently half a million members, the majority
of whom are women. The repayment rate is extremely high at 98% and the scheme has become
a model of participatory development70. An independent evaluation of the programme found that
villages which have adopted the scheme, benefited from a lower poverty rate, higher employment
rates, and higher assets levels than villages which have not developed a local branch of the
scheme71.
There are however caveats to credit schemes - although credit may be granted to women, they
may not always have control or decision-making power regarding its use, and in some cases they
do not even benefit from the loans, as was the fate of some of the women who belonged to the
Grameen Bank credit scheme in Bangladesh where loans provided to women were invested by
male relatives72. Secondly, an increase in income is not enough to guarantee the poor a
sustainable existence - the loans may be used to pay back a debt or for health services - and the
poor may become even more vulnerable as well as indebted. The need therefore to improve
access to social services is essential if the poor are to benefit from their increased productivity.
While credit schemes can offer opportunities for the poor, they do often not reach the poorest
people who may also be hesitant to join the scheme for fear of becoming indebted.
20
10.3
Promotion of education - investing in women
1 he role of education and in particular primary education has long been recognized as one of the
most important determinants of human welfare, opportunities and economic growth. This has
been amply proven by the investments in education which have been undertaken by South-East
Asian countries experiencing rapid economic growth. According to the World Bank, the
differences in growth experienced by these countries compared to other developing countries is
largely due to their investment in education.73
There is today, broad agreement of the importance of education of women for health status.
Despite this, of the 840 million adults who are illiterate, 538 million are women.74 Lack of
education opportunities for women and girls which is still prevalent in many developing
countries, reflects a deep rooted structure of gender discrimination which denies women and girls
opportunities of participation in society. Not only does this limit women’s possibilities of earning
income, but it also leaves them in an extremely vulnerable position if they are left alone to head
the household.
Many countries such as China, Costa Rica, Sri Lanka and the State of Kerala in India, have
recognized the importance of female education and have given priority to this in overall
development strategies to improve women’s status and opportunities. In response to the vicious
cycle of deprivation which women face, many groups, notably NGOs and community
organizations all around the world are engaged in activities which increase opportunities for
women. Programmes are often combined with several capacity-building activities such as
nutritional programmes, literacy training, awareness raising and problem solving activities.75
One of the current obstacles to primary education of girls is that it will take them away from
essential domestic tasks such as wood and water collection and child care. Anti poverty
strategies which encourage girls to attend school will therefore need to provide incentives which
take this into consideration such as flexible school hours and communal water and fuel
provision76.
10.4
Poverty alleviation programmes and targeting the poor
As a result of decreasing public resources, Structural Adjustment Programmes and privatization,
many developing countries are “targeting” scarce resources to the most needy. The type of
activities and programmes vary between countries, and may include rationed food subsidies.
supplementary feeding programmes, employment and public works programmes, food stamps,
subsidized food shops and assuring basic food at low cost77 . While some countries have
experienced a positive impact on the welfare of low income groups as a result of the
21
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programmes78, it is important to be aware of the dependency that such programmes may create.
Furthermore, although poverty alleviation programmes of this kind are aimed at the poorest
populations, evidence shows that they are often not able to reach their objectives.
The “target” approach involves interventions which have been initiated by others than the poor.
Poor people are seen as “ targets rather than decision-makers cum actors capable of improving
their own condition, given the right incentives and skills”79. Other anti-poverty programmes
while declaring themselves in favour of empowerment of the poor, have not moved beyond the
rhetoric of community participation and insufficient action has been taken to actively include the
poorest people in all the processes of development of the programmes80. In some cases, political
use of programmes for partisan purposes, top-down implementation and centralism have further
weakened peoples’ participation at local level and to the extent that existing local self-help
groups have been undermined81.
The question of targeting also raises an important consideration with respect to long-term
sustainability and improvement of conditions for the poor. While in many cases, the programmes
are important and do contribute to alleviation of poverty in a difficult period, they address only
the manifestations of poverty and seldom have an impact on the conditions of the poor and the
underlying causes of poverty. They cannot resolve long term poverty and this seems to suggest
that the long term impact of such programmes may be limited.
10.5
The participatory approach - partnerships with NGOs and civil society organizations
and community groups
An alternative approach adopted by many NGOs, community groups and civil society
organizations, is the participatory approach which involves the poor themselves in all aspects of
the formulation of social policy, including situational analysis of the existing social, political and
economic causes of poverty, definition of the main problems encountered, and formulation of
possible solutions to the problems.
This approach is being adopted by many governments and NGOs since there is increasing
evidence that when the poor themselves are involved as actors and not merely objects in the
development process, the chances of influencing and achieving human development and equity
are significantly strengthened82. Innovative activities are often built on the concept of
empowerment of people. Methodologies such as Rapid Rural Appraisal, Participatory Action
Research and Popular Education based on the ideas of liberating education by Paulo Freire, are
used to reach the goal of enabling the communities to analyse and seek solutions to their
problems.
22
11.
Health sector involvement in the eradication of poverty : an option or an
imperative?
Whether or not the health sector can or should play a role in the eradication of poverty is no
longer a relevant question. Health services are already deeply involved in trying to cope with
the consequences of the increase in poverty in all regions of the world, treating new outbursts of
disease which were thought to be controlled; responding to the increase in ill-health; attempting
to provide adequate levels of health care with increasingly scarce resources; facing people in
need but unable to respond to their needs because of shortage of drugs, supplies or staff;
witnessing deaths and permanent disability which could have been prevented... However,
managing the consequences of poverty is not enough. The health sector is paying a high price
for the lack of political will to invest in health determinants. The question today is rather how
health professionals, health services and health policy-makers can best contribute to the process
of eradication of poverty.
12.
Summarizing the interaction between poverty and the health care establishment
The main dimensions of the interaction between poverty and the health sector can be summarized
as follows:
From the perspective of the poor.
•
Lack of adequate free or low cost health services may contribute to further
impoverishment of the poor. Cost-sharing or fees-for-service may deter the poor from
attending health services and lack of resources to pay for transport may deter poor
people from attending preventive health services such as immunization or ante-natal
care. Scarce resources may be used on drugs at the cost of essential food products which
in turn may cause other health problems such as child malnutrition.
•
Poor quality of services such as inadequate attention by the physician, lack of available
drugs, long waiting times, absence of doctors, ineffective treatment and the charge of
“extra”fees” may also discourage the poor from attending health care services83.
•
Health services which are provided at a high social cost (long distances to health
facilities, many hours away from renumerated work) to the poor may contribute to the
depletion of their assets through loss of capital and precious time.
•
Health services do not adequately take into consideration or build on local structures
23
and community coping mechanisms which may already exist to reduce the effects of
poverty and to improve health.
From the perspective of health services
•
Poverty undercuts the ability of the health sector to carry out its responsibilities
adequately and it also increases costs. For example, treatment of infectious diseases is
hampered by constant exposure of people to insanitary living conditions; preventable
illnesses may be presented at a late stage when complications have set in; and medical
treatment may be discontinued due to a lack of resources to pay for drugs.
•
Decrease in use of health services may lead to reduced income for health services which
in turn may affect the efficiency and effectiveness of the health services. Decrease in
use may also affect the staff morale and quality of care.
•
Lack of health professionals in rural areas may be linked to a lack of opportunities for
medical doctors to earn a living. In many countries, medical doctors are therefore
resistant to working in these areas and this may influence the treatment of patients and
their attitudes to the local culture. The emphasis of the medical training of most doctors
is technical and does not take into account the link between health and development or
poverty and health.
•
The lack of understanding about poverty and of the multi-dimensional aspects of
poverty may also influence the choice of health services which may not always be to
the benefit of the poor (e.g. certain essential clinical packages which do not take into
consideration the multi-causal nature of ill- health).
•
Disease has an impact on the individual as well as the household. Neglect of this may
lead to inadequate and unsatisfactory treatment methods which focus on individuals
rather than all members of a household.
•
The health of other adults and in particular of the breadwinners, is critical for the health
and nutrition of children.
•
Women are disproportionately affected by poverty exposing them to greater health risks
which lead to higher morbidity and mortality. Lack of adequate health services adapted
to the needs of women substantially increases these health risks.
•
The health sector has a broad network of professionals to draw from - in no other sector
24
is there such an organized network of people directly involved with the poor. The
potential of this network in poverty eradication is currently insufficiently exploited.
13.
Poverty eradication and Health For All
The above considerations call for a response from the health sector if Health For All is to remain
a valid goal today. The vision of Health for All which was launched at the Alma Ata Conference
in 1978 is a vision of “ the universal attainment by the year 2000 of a level of health that would
permit all people to lead socially and economically productive lives. The call for Health For All
was - and remains, fundamentally- a call for social justice”84. Primary Health Care (PHC) was
seen as the most practical approach to achieving the overall objectives of Health For All. Inherent
in the PHC approach was an implementation strategy for community involvement in determining
health care and health status. Poverty eradication and any policies within the health sector
aiming to address the problem of poverty will therefore need to be based on the principles of
equity and increased participation of people in decisions and events which will affect their health.
Equity is understood here as a concern for “fairness” which includes the notion of social justice
and the fair distribution of the benefits that accrue to a society and the goal of equity is to
eliminate the differences in health status of different groups in society.
The increase of poverty in many countries suggests that we have a long way to go in attaining
Health For All and that much of the commitment to Health For All seems to have gone lost over
the last decades. The comprehensive approach reflected in PHC has given way to “piecemeal”
approaches within health systems. Conflicting concepts of health have developed. Health is
promoted by some as a commodity and something which can be bought or sold while others see
health as “prerequisite both for overall human development and for maintaining peace and
security without which economies cannot develop and thrive”85. Some suggest that the health
sector is at a crossroads and the future of innumerable people trapped in poverty will depend on
which way it chooses to go: “Countries need to know that either they continue the current trend
of diminishing access to comprehensive health services through a market approach to financing,
provision and allocation of medical services, or they embrace a radical reorientation towards the
development of health systems whose goal is the improvement of the health and well-being of
entire populations, giving priority to those with greatest needs.”86
25
14.
Basic principles and strategies for health sector involvement5
While it is clear that poverty eradication will not depend on the efforts of the health sector alone,
health professionals, health systems and health policy-makers do have an important role to play
by pursuing effective health interventions which will reduce health inequalities and by
mobilizing support for the creation of an informed, supportive, and health-enabling environment
necessary for the pursuit of health for all. For this, the values of the vision of Health For All need
to be interpreted into basic principles which can guide the choice in health care development.
14.1
Equity in health care
The underlying principle of equity in health care requires that it be distributed according to need
and regardless of ability to pay. In practical terms this means providing universal access by the
poor to comprehensive, good quality health services without regard to financial barriers. The
government will need to assume a key role in ensuring that the principle of equity is interpreted
into specific and concrete actions through the design and monitoring of the overall health policy.
14.1.1
Equity in access and health care financing
One of the most important contributions the health sector could make to poverty eradication is
to pursue mechanisms of financing health care which protect the most vulnerable. Many
examples of such mechanisms aimed at creating equity can be found which include development
of social security systems which cover curative services for the underprivileged, community
financing schemes aimed at empowering the community, payment on the basis of income,
exemption of payment for health services for those unable to pay, financing of public health
activities through tax, and subsidy to private providers and NGOs offering services to poor
communities.
When considering ways of protecting poor people from payment, it is important to note that
although exemption from payment is important, their implementation in practice is not always
straightforward. Even where exemption policies have been designed to protect the poorest
people, practical, institutional, and social difficulties may render them inadequate 87. Some
schemes have opted not to exempt anyone and require even the poorest people to pay a “token”
contribution. To ask poor people to pay something might guarantee their right to a service. In this
way they may also avoid a certain stigma. This has been the practice of the Gonoshasthya
Kendra health care system in Savar, a non-governmental organization in Bangladesh in the
development of a community health insurance scheme.
Adaptation of basic principles proposed by Nick Spencer in Poverty and Child Health p 212-214
26
A study which looked at equity and financing of health care in developing countries, found that
despite the existence of explicit objectives of government policies and despite the efforts which
governments have made to provide equal access to health for everyone in need, many countries
have failed to generate an equal distribution of health care utilization88. One of the main reasons
for this may be the bias which has emerged towards urban-based hospital care over basic
preventive measures and the inadequate portion of the budget allocated to rural areas. Equity in
health care financing may therefore need serious reconsideration of the allocation of resources.
This requires a clear commitment by the government to allocate adequate funds to the poorest
areas and to ensure that the health needs of the regions are well represented in the health budget89.
The public health sector remains, in principle, the main source of health care accessible to poor
people. It therefore has a responsibility to advocate for government commitment and to make
sure that the funds actually do reach the areas and people most in need. It is important to note
however that, although crucial to the health of poor people, allocation of health services may not
be enough to reach the poorest populations. Alternative provisions such as outreach programmes
may therefore need to be developed.
Greater equity in the distribution of health services may be achieved through the involvement
of communities themselves in development of the infra-structure and in decision-making
regarding resource allocation and health care. Community monitoring of the performance of
health services will also enhance accountability of health services to the population90.
14.1.2
Promoting gender equity
In view of the burden of poverty that falls on women and the increased risk women suffer due
to this, it is vital to ensure that health services are made available to women. This calls for
sensitivity and respect for the cultural context in which women live since it may influence access
of women to health services. An understanding of the role of women in their communities and
families will enable health workers to make more appropriate choices regarding the health
services offered to them. The specific needs of women (such as reproductive health needs) should
be given priority and responded to in a way which is not limited to technical interventions but
in the true spirit of PHC, contributes towards the well-being and empowerment of women and
equips women with the necessary tools and knowledge to reduce health risks (e.g. increased
domestic violence, illegal abortions and high-risk pregnancies). Reproductive health services can
play a major role in creating a “legitimate” space for women to discuss, organize, and overcome
barriers to their health and well-being.
27
14.1.3
Protecting the health of household wage earners and producers
The health problems of women should also be considered from the household perspective. While
many health and nutrition programmes are concerned with mothers and pre-school children, the
health of other adults and in particular the breadwinners, is critical for the health and nutrition
of children. New health policies are therefore required to identify the mechanisms and means to
meet the health needs of all household members. In particular the health of household wage
earners and producers must be protected and improved. Moreover, health services at district
level must become more geared to providing outreach contacts to remote vulnerable households,
including the dwelling migrants whose temporary periods of work may provide the means of
survival to their families living elsewhere.
14.2
Protecting the assets ofpoor people by adapting health services to their needs
When considering costs in health care and access to health services, it is important to take into
account the social costs incurred by poor people and barriers to access. Health services which
require that poor people pay a high price in terms of long walking distances and long waiting
hours may contribute to the depletion of their assets through loss of precious time which could
be invested in income generating activities or in agricultural production, or loss of capital due
to transport, drug and treatment costs. The health sector can therefore contribute to poverty
reduction by making efforts to reduce these social costs. This demands a great deal of flexibility
on the part of health services and concerted efforts to explore alternative methods in health care
delivery such as community outreach programmes, introduction of opening hours which are
adapted to people’s needs and the provision of transport facilities to the sendees. Flexibility is
also needed on the part of health professionals, to become involved in issues which are not
exclusively medical.
For example, a group of medical doctors working in Matagalpa, a coffee growing region of
Nicaragua, were made aware of the high social costs incurred by plantation workers in seeking
health care at the main health centre. This spurred the medical doctors to meet with the owners
of the coffee plantations to discuss the possibility of setting up a small health centre within the
plantation which could be run by health workers visiting the plantations on a regular basis.
Negotiations led to agreement by the plantation owners to contribute towards the costs of the
health centre and to allow the workers to visit the centre and participate in health promotional
activities including training of community health workers during working hours91.The
importance of such initiatives is that the assets of the poor are protected whilst at the same time
health services are contributing towards improving their health status. This ultimately benefits
the plantation owners through increased production capacity.
28
14.3
Acceptability and relevance
Policies and strategies need to take into consideration not only the geographical distribution and
the quality of care but also the need for information on the health care services so that they are
understood and accepted by the population and perceived as relevant.92 Health professionals and
communities may not always share a common concept of health or health problems, nor will they
always be in agreement about how to tackle the health problems. This may lead to the
development of health services which are unacceptable or irrelevant to the communities and
therefore not used93. The case of Kisembo (Box 2)94 reflects the need for health professionals to
pursue opportunities to better understand traditional medical practices and the broader
implications of this on the well being and social cohesion of the community.
The
political
structure, decision-making
processes, the cultural beliefs, traditions and [ With regards to health problems, an experience ;
subsequently the status of women all form part of I from a health center in Zaire illustrates the tension I
I which may exist between “western" medicine and ;
the local context which needs to be taken into I traditional beliefs. Despite the fact that Kisembo's I
consideration. Rural populations may be more I mother had taken him regularly to the pre-school [
participated in the health education sessions |
isolated than urban communities from national |I clinic,
and had made sure he was fully immunized, he I
political developments and they may be much | died of kwashiorkor. When asked about his |
more dependent on the local political structures I condition, the mother informed the nurses that he I
j had been miserable for several weeks leading up to |
and hierarchy for decision-making, support and I his death. When asked why she did not bring I
advice than on government authorities or health I Kisembo to the hospital she answered that “ He ;
' was not sick, he had lost his peace. Misery cannot 1
services95. Awareness by health professionals of I be cured by foreign medicine. I took him to the I
these structures will help to identify how a I traditional healer but he could not help either”.
i_
_ ________________________________________________________ j
community should be approached, how Box 2 The importance of understanding traditional beliefs
community health leaders should be identified,
and the manner in which decisions should be mad :, both within a family and in the community
as a whole.
In many cases, local health services have neglected the importance of the local process and have
set up parallel structures such as village health committees which may find themselves in
conflict with the traditional structures and decision making processes. The health committees set
up by health services may not be relevant or acceptable to the local communities who as a result
will not support them. Building on the local structures and strengthening them, will contribute
towards making health services more relevant to the local context.
29
14.4
Participation of the poor in health development
Broad involvement of people themselves in health development is the only way to reach Health
For All. Although this message has been repeatedly stressed and agreed on in many documents
and declarations since the Alma At Conference, insufficient attention in practice, has been given
to transforming words into reality. For health services, this may mean opening up the process of
participation and decision-making to community representatives to discuss issues directly or
indirectly affecting the life of communities and to facilitate their effective participation in all
aspects of health care96. It may mean visiting communities, listening to their concerns and
including them in the design, management and control of health services. It may mean being
prepared to learn from the poor who are the experts on poverty, to change and to adapt.
This participatory approach recognizes the strengths and resources of the poor communities
including existing community-based structures, and seeks to facilitate and enhance these
strengths, both on an individual and collective level. The underlying principle of the approach
is to promote growth and equity and to strengthen the democratic process at a local level through
a bottom up process which enables the poor to become full participants in development and
decision-making97. Although “ participation alone cannot overcome all the barriers to health
arising from economic and social deprivation, [..] given a positive climate created by an equitable
social policy, communities can become empowered to improve the health of their households”98.
Community-based health programmes which apply these principles of participation can be found
all over the world. In some cases communities have taken on the task themselves of organizing
activities, self support groups and actions in favour of the poorest; in others cases, partnerships
have developed between the local health services in particular the health services and the
communities.
However, community enabling and community organization is not without problems - the
process does not give instantaneous results, nor does it deliver goods immediately which is what
some people expect99. The process is one of individual and collective growth, of awareness
raising and one which ensures that the poor assert their rights - to health, to dignity, to
participation in decision-making and to their fair share of resources. For health professionals,
this may pose a major challenge. Increased participation of people means increased access to
information, decision-making and power. In the process, health professionals may see their own
power diminish and to accept this will require a change of attitude for many medical doctors. The
change will not be easy.
Participation is not passive and awareness raising can lead to concerted action of the poor which
may challenge authorities and decision-makers who are not prepared for this. In some places this
30
has led to increased social tensions, confrontations and deliberate actions of authorities to
suppress the initiatives taken by the poor. Efforts need to be strengthened on the part of local and
national health authorities to be responsive to the needs of the poor and to include them in a
process of decision-making based on true partnership and collaboration. Not only will this
process diminish tensions but it will have a greater chance of success.
A multi country study undertaken by WHO and which looked at the role of civil society in
District Health Systems, clearly demonstrated that each programme or intervention must be
adapted to the local situation and needs of the people, and each situation treated within its own
right100. There are no generic strategies which can be implemented and used as models and a
great deal if sensitivity and respect is needed to each situation.
14.5
Training of health professionals
The above study also pointed to an important shortcoming within the health sector. While health
professionals often have a great deal of experience and systematic ideas about health, they often
lack knowledge and understanding of the development process and of the link between poverty
and health. A study from India which looked at participatory research in universities highlighted
the existing tension between the training which medical doctors receive and demands which
await them in practice. "Currently, many universities disable students who pass through them,
conditioning them with attitudes and behaviour based on a feeling of superiority and teaching
methods which have to be unlearned as they prove ineffective in field situations”101. An
alternative university training which enables students to be sensitive, humble, to listen, to be self
critical and to enable others requires basic changes in both the university system and the health
system. Awareness raising of health professionals to the importance of civil society
organizations in health development and to participatory action research to develop skills,
instruments and methodologies to promote strategic local health planning and management will
also require serious consideration by policy-makers of the cunent medical curriculum.
Encouraging experiences of introducing participatory methods into universities and government
institutions do point to promising developments which may also influence research on aspects
of health and poverty in the future. One such example is The Network of Community-Oriented
Educational Institutions for Health Sciences, an international network which aims to strengthen
and mutually support the members in curriculum development for community health.
14.6
Information and data monitoring
In order to develop suitable responses to the problems caused by poverty, adequate data is needed
which monitors both health trends and the distribution of poverty in a population. However, the
current practice of producing average data masks the real indicators in disadvantaged population
31
0515e
/or
groups, concealing existing disparities in health status and health care. In many countries lack
of data may also be a problem. In order to identify disparities it is vital that routine data related
to health is collected according to socio-economic status, sex, clan and region. The parameters
used to measure and adequately reflect differences in socio-economic status and the process of
information collection will need to be developed at country level. The involvement of the poor
themselves in research, information collection and monitoring the situation of poverty and health
should be sought, using methods such as the Participatory Rural Appraisal which includes data
analysis, interpretation and use102.
Universities and research institutions could play a significant role in bringing information to the
attention of policy makers, encouraging poverty eradication which is more effective, flexible, and
appropriate. Changes in the health status of the poorest groups as a core indicator of poverty
eradication should be promoted and adopted at national and international level.
14.7
Intersectoral collaboration and partnerships in health
The multi-dimensional character of poverty will require a response which includes many sectors
and many actors, private, public and within civil society . Both the Ministry of Health and health
systems have a major leadership role to play in this by mobilizing commitment to health as an
integral part of development and in influencing policy and actions in other sectors. By
monitoring the health and poverty effects of sectoral interventions and programmes, and by
participating in intersectoral discussions such as round tables and NGO forums, the MOH and
those involved in health are also in a position to analyse the trade-offs related to other sectors.
Suitable mechanisms should also be sought which encourage other sectors to consider the health
impacts of their interventions. In Sweden, where political commitment to equity is high, public
agencies are required to pursue goals which reduce socio-economic inequalities and to analyse
the health impact of all national policies103. The MoH could play an important leadership role in
this by promoting the integration of health objectives into the respective policies of all sectors
so as to ensure the elimination of exposure to health risks by the poorest as well as to strengthen
the impact of those sectors whose activities can improve health.
Change calls for political action at the highest level and partnership building between
government, NGOs, professional health associations and civil society can stimulate this change
through promotion and advocacy. In Brazil, where there are dramatic disparities between rich and
poor, an anti poverty campaign was launched in 1993 which has succeeded in mobilizing large
parts of the society including trade unions, churches, community organizations, the private
sector, banks, professionals, students and women’s groups. The aim of the Campaign against
Hunger, Misery and for Life was to “raise awareness within Brazilian Society of the rights and
32
responsibilities of individuals and social groups, and of the need to tackle poverty.”104 The
campaign has worked at local level, creating job opportunities and assistance in the form of food
donations to the poor; it has been instrumental in the mobilization of the poor to put pressure on
local and federal authorities to address poverty issues; and it has been successful in securing
government support and in shaping government policy in favour of social equity105. It is a unique
example of how State, NGOs and civil society have come together to work against poverty. One
of the outcomes of the campaign, a prerequisite for the creation of an social environment in
which poverty eradication can take place, is that it has “ awakened a spirit of solidarity and
public responsibility, which is important against a background of growing fear, violence,
insecurity and lack of hope”106.
14.8
Strengthening of Ministries of Health
A recurrent problem in many parts of the world is that the MoH is not adequately equipped to
tackle the multiple requirements of intersectoral action and poverty reduction. Many national
MoH are entirely preoccupied with budgets and the specifics of health sector reform and have
little time to develop their new leadership role to ensure that health is high on the national
development and political agenda. Furthermore, the MoH in many countries has a relatively low
status in the government and subsequently health policy is given little attention. This situation
requires that the MoH is strengthened in its negotiating role and that it actively pursues
opportunities to develop capacities in the area of economics, policy analysis and planning, and
legislation.
14.9
Advocacy
The health sector has a broad network to draw from - in no other sector is there such an organized
network which ranges from health committees at the local level to associations of health
professionals at national and international level. The human resources and in particular the health
professionals which could be mobilized against poverty are far reaching and many health
movements worldwide are recognizing this potential and taking initiatives to come together to
analyse, advocate and act for the advancement of policy solutions which promote health.
Conferences on health and poverty are being organized, such as the one held recently in London
in March 19966 which brought together representatives from institutions and bodies representing
A series of international meetings have been sponsored by ICO/WHO on the theme of
poverty and health. They include a Congress in Baltimore 1997 on the theme
"Investment Strategies for Healthy Urban Communities", a meeting in London 1995
which drew together health professionals, one in Ireland 1996 which targeted national
and international NGOs and one in London 1997, a follow-up to the Baltimore meeting.
Reports are available from ICO.
33
health professionals, to look for ways in which to reduce the harmful effects of poverty. Greater
coordination was called for between international agencies, NGOs and professional groups and
recognition was given to the fact that health professionals have a specific role to play by
“ showing their indignation at the continued wastage of humanity and acting as advocates for
effective policies to reduce poverty and its consequences for health”107.
14.10
But not without the non-poor...
Most studies on poverty have focused on the poor108 and more should be done to involve the non
poor if any change is going to be sustainable. The task today should be to tackle the underlying
causes of poverty and not only try to address the manifestations of poverty. This means that
efforts must be made to reverse the current trends and to involve the non-poor in serious self
examination.109 Urgent questions need to be considered and answered by the non- poor
themselves: to what extent are they willing to examine their own role in sustaining and creating
poverty? What images do the non-poor have of the poor which influence their behaviour and
decision-making?110 Are people who have gained economically prepared to forego further gains
in order to reverse the trends? 111 Poverty and the poor cannot be treated as a “phenomenon that
can be understood in isolation of society at large”,112 and the fact that poor people are living in
symbiosis with the rest of society should therefore be the starting point of future research and
consideration.
15.
From principles to action
It is becoming increasingly clear that the existence of a strategy, policy or principle is no
guarantee that action will be taken to implement it. The experiences of implementation of anti
poverty strategies and health policies aiming to reach the poorest suggest that problems have
developed which were not envisaged at the start of the process. Many factors which seem to have
little to do with the content of the strategy have played a role in determining the extent to which
an intervention has yielded the desired results. Elements which most seem to influence the
success of a strategy such as community involvement, power relations, cultural traditions and
structures, political manipulation or lack of management, have just as much, if not more, to do
with the implementation of the strategy or policy than with its content. In considering the role
of the health sector in poverty eradication, attention should therefore not be limited to focusing
on the objectives and content of the policy or intervention; more attention needs to be given to
the context in which the strategy has been developed, to understanding the process of
implementation, and to the actors involved in shaping or implementing the policies.
With this in mind, a simplified framework for action is proposed in table 3.
34
TABLE 3
A FRAMEWORK FOR ACTION
PRINCIPLE FOR ACTION
IMPLICATIONS
Strengthening the capacity of health
systems both informal and formal
Protecting and improving the health status of the poorest groups as an
essential element in poverty eradication.
Defining roles and functions of the health system as an integral
component of national poverty eradication strategies and programmes.
Advocacy
Mobilizing the health professional network at national and international
level, to participate in poverty reduction and the creation of an enabling
environment.
Critically analysing policies and practices and informing policy-makers.
Strengthening MoH
Developing capacities in the area of negotiation, economics, policy
analysis and planning, and legislation.
Political support.
Intersectoral collaboration
Mobilizing commitment to health of all sectors.
Promoting the integration of health objectives into the respective
policies and actions of all sectors.
Promoting the adoption of changes in the health status of the poorest
groups as a core indicator of poverty eradication .
Creating and mobilizing partnerships with groups in civil society.
Promoting participation of the poor
in health development
Opening up the process of decision making to communities by letting
go of power by authorities and those in powerful positions.
Supporting and facilitating community participation.
Recognizing and enhancing community strengths and assets.
Practising sensitivity and respect.
Protecting the assets of the poor
Ensuring equity in health
Protecting the most vulnerable who cannot afford to pay .
Ensuring provision of adequate funds to poor areas.
Ensuring that quality health care reaches the poorest.
Promoting gender equity
Making health services available to all women.
Creating space for the participation of women in decision-making.
Developing a household approach to
health care
Responding to health needs of all members, in particular the
breadwinners.
Active outreach to poorest households.
Increasing flexibility in adapting
health interventions to the needs of
the poor
Reducing high social costs for the poor through innovative activities
e.g. community outreach programmes.
Ensuring acceptability and relevance
Increasing information on health services.
Increasing knowledge of communities and the coping mechanisms of
the poor.
Sensitivity and respect for cultural and traditional health practices.
Recognizing and strengthening local structures.
Data collection and information
Collection of disaggregated data.
Involvement of the poor in data collection and research.
Training of health professionals
Awareness raising of the link between health and poverty.
Promoting a change of attitude from medical to social.
35
16.
Concluding remarks
The health sector has an important role to play in the eradication of poverty and through its
network of health professionals worldwide, it has the informal and formal structure needed to
take on the challenge at local, national and international levels. The process of poverty
eradication will demand innovative thinking and combined efforts among people who believe
that it is possible.
No single political, social or economic intervention or sector can resolve the complex problem
of improving the quality of life and reducing poverty, suffering and deprivation. New integrated
approaches need to be explored in which "the emphasis is placed both on improving the
capabilities of the poor, through the provision of health care, education, and productive assets,
and on creating an enabling environment in which those capabilities can be realized.""3 The
process will only be successful if there is active participation of the poor people themselves and
if the focus of poverty is broadened to address the role of the non-poor part of the population who
need carefully to consider also their role in creating and sustaining poverty114.
One of the aims of advocacy, coordination and collaboration in poverty eradication at all levels
should be to develop consistent, coherent and unambiguous global consensus on the values and
principles for poverty eradication. Poverty is both global and country specific. The global causes
of poverty must be tackled from a global level by the broad international community including
the bilateral and international agencies such as the UN agencies and the Bretton Wood
Institutions, International Non Governmental Organizations, Civil Society, the Private sector and
peoples’ movements. Country specific implications of poverty should be addressed at the country
level also by the broad range of actors.
According to UNDP calculations, the additional cost of providing basic social services to all in
developing countries for the next ten years amounts to $40 billion a year. In a world economy
of $25 trillion this represents 0.2% of the global income and less than half of the combined net
worth of the seven richest men in the world"5. Poverty eradication is not about lack of resources.
36
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43
N° 25:
Methode d'analyse de I'aide extdrieure a la santd : I’exemple du Tchad - Document pays - WHO/ICO/MESD.25
N“ 26:
Health and poverty in the context of country development strategy: a case study on Bangladesh - Country
document - WHO/ICO/MESD.26
N“ 27 :
Methodology for identifying the poorest and most vulnerable people at local level - Technical paper WHO/ICO/MESD.27
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