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“Macroeconomics,
Health and
Development” Series
Number 29
WHO/ICO/MESD.25
Original: English
Oistrjbution: Limited
Poverty and health:
aligning sectoral
programmes with
national health
policies
Division of intensified
Cooperation with Countries
in Greatest Need
Policy paper
■;r;
B
1
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V\>orld Health Organization
Ogneva, April 1998
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*
Poverty and health:
aligning sectoral
programmes with
national health
policies
Debra J. LIPSON
Consultant,
Division ofIntensified Cooperation with Countries
and Peoples in Greatest Need
World Health Organization, Geneva
ADDRESS FOR CORRESPONDENCE REGARDING THIS DOCUMENT
Debra J. Lipson
World Health Organization
ICO
20 avenue Appia
1211 Geneva 27
Switzerland
Tel.+ 41 22 791 25 03
Fax.+ 41 22 791 41 53
This document is not issued to the general public, and all rights are reserved by the World Health Organization
(WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior
written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any
means - electronic, mechanical or other - without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of authors.
Printed in 1998 by WHO
Printed in Switzerland
ii
H E - I 00
0515;
k:
1 V 0°'
CONTENTS
ACKNOWLEDGEMENTS
. iv
EXECUTIVE SUMMARY
v
INTRODUCTION AND PURPOSE
1
1. POVERTY ASSESSMENT ................................
1.1 Participatory poverty assessment............
1.2 Official poverty assessments..................
1.3 Enhancing poverty assessments for health
3
3
4
4
2. ASSESSING DETERMINANTS OF HEALTH AMONG THE POOR ..
2.1 Grouping cause of death into common risk factors ....................
2.2 Analysis of key health and socio-economic indicators................
2.3 Sub-national "Mapping” of health disparities..............................
2.4 Attributing disease burden to risk factors associated with poverty
2.5 Health impact assessments of development projects ..................
. 6
. 7
. 8
. 9
10
12
3. SETTING PRIORITIES AMONG SECTORS................................
3.1 What the poor regard as most important to their health .. .
3.2 Ministries with which you are on good terms....................
3.3 Political factors..................................................................
3.4 Priorities of donors............................................................
3.5 Distributional impact on the poor's health "stock"............
3.6 Distributional impact on the economic activity of the poor
3.7 Direct impact on health......................................................
3.8 Multi-sectoral balance sheets ............................................
3.9 Multi-sectoral cost-effectiveness (CE) comparisons ........
3.10 Using the criteria to set priorities......................................
14
16
16
16
16
17
17
17
18
18
20
4. INTERSECTORAL ACTION FOR HEALTH - CASE EXAMPLES.............................. 22
4.1 Microenterprise development and community economic development............ 22
4.2 Agriculture and food policy ................................................................................ 24
4.3 Education policies................................................................................................ 26
4.4 Macroeconomic policies...................................................................................... 26
4.5 Environmental and infrastructure projects to improve water andsanitation ... 27
5. INITIATING AND MAINTAINING INTERSECTORAL ACTION
5.1 Prerequisites for intersectoral action..................................
5.2 When to initiate intersectoral action for health ? ..............
5.3 How to initiate and plan intersectoral action ....................
5.4 Implementing and maintaining intersectoral action..........
30
30
30
31
31
REFERENCES
33
iii
Acknowledgements
The author extends sincere appreciation to several individuals who made generous contributions
to this paper. Michel Jancloes, Director, and John Martin, Assistant Director of the Division of
Intensified Cooperation to Countries and Peoples in Greatest Need at WHO provided the inspiration for
this paper and helped to ensure that it remained focused on those who might benefit from its content -poor people in developing countries. Thanks are also due to several ICO staff who identified how the
paper’s major points could be clarified, strengthened, or illustrated: Guy Carrin, Haile Mariam Kahssay,
Carole Landon, Garry Presthus, Margareta Skbld, and Eugenio Villar Montesinos. Derek Yach, of the
Policy Action Coordination Team at WHO, offered encouragement and thoughtful comments at various
points in the paper's development. Isabelle Gaiddon provided final editorial assistance.
Debra J. Lipson
3 April 1998
iv
EXECUTIVE SUMMARY
Health improvement of the poor and poverty reduction are two sides of the same coin.
Better health makes it more likely that the poor can take advantage of economic opportunities.
And improvements in the poor's standard of living will contribute to better health. Health policy
makers tend to focus their attention on the first part of this equation by seeking to improve the
health of the population through the provision of health care. Yet, they may be missing
important opportunities for health improvement of the poor by not actively participating in
poverty reduction efforts with other sectors.
This paper is designed to stimulate national policy-makers and advisers in developing
countries to consider the value of intersectoral action for poverty reduction as a strategy for
easing demands on limited health system resources. It also provides guidance to national policy
makers and their advisers on how to set priorities among other sectors with which to work in
reducing poverty, so as to use limited resources most productively.
To set priorities among other sectors, the paper stresses the need to understand the
characteristics of the poor in each country and the major causes of poverty which help identify
the potential contribution of various sectors to its amelioration. It discusses methods for
identifying the major determinants of health among the poor specifically, which can help point
to specific sectors for coordinated efforts. These methods seek to identify common risk factors
for diseases affecting the poor, and effects of other sectors' development policies on their health.
Setting priorities among other sectors should be based on which ones present the greatest
risks to health or are most likely to improve health. However, given common limitations in data
and information needed to determine this in most developing countries, a number of other criteria
for choosing among sectors are proposed that are less data-dependent. The paper stresses that
all affected stakeholders be involved in choosing the criteria for deciding which sectors deserve
highest priority, and in applying the criteria to the selection of potential intersectoral activities.
Examples of intersectoral programs in five key areas are described to show that such
efforts have reduced poverty or improved the health of the poor in developing countries. These
include community economic development, agriculture and food policy, education,
macroeconomic policy, and environmental and infrastructure projects for safer water and
sanitation.
V
The paper concludes by briefly discussing the biggest challenge to intersectoral action:
how to get the process started and keep it going. The ability of the health policy-makers to align
other sectors' development programs for health depends on several prerequisites. Health
professionals must recognize that poverty reduction is a key strategy for improving the health
of the poor. The public must understand that better health is an integral part of community and
economic development and the poor must be ensured opportunities to participate in initiatives
on their behalf. Public and private organizations must put pressure on policy-makers to make
health considerations more central to development policies. Finally, the Ministry of Health must
have the technical capacity to advise other sectors about modifications to their activities that
would improve health and reduce poverty more effectively.
vi
INTRODUCTION AND PURPOSE
Improving equity in access to health care for all is the cornerstone of nearly every
country's health policy. Yet, the contribution of health services to improved health status is
relatively modest compared to other factors (Evans, Barer and Marmor, 1994). The key
determinants of health are higher income, higher levels of education, better nutrition, access to
safe water and sanitation, and safe and adequate housing. For the poor in particular, investment
in health care will be less effective in
improving their health without adequate 1 Health status improvements require more than
attention to improving their human capital health
services alone
—
generally, via nutrition, education, and
enhancing their income-earning potential,
and to the immediate environment in which
they live and work (Gunatilleke, 1995).
Thus, to improve health of the poor, one
must pursue a broad array of strategies,
many of which do not involve direct
provision of health care services.
Sweden’s long and steady decline in infant
mortality, “was initially attributable to gradual
improvements in nutrition, hygiene and
environmental conditions. In other words it began
long before specific medical interventions such as
mass vaccinations and anti-bacterial therapeutics
were introduced.” (WHO, 1997b, p.l)
Though the need for intersectoral action for health has long been recognized and
promoted, it has not been widely implemented. Often, other sectors do not appreciate the impact
of their actions on health or are unwilling to change to ameliorate the damage caused to health,
or contribute to its improvement. But in many instances, those in the health care system itself
are to blame. The problems and inadequacies of the health care system can be so overwhelming
that health leaders may believe they cannot spare the time to work with other sectors. In many
cases, health professionals do not have sufficient information about the impact of other sectors positive or negative - on the health of the population to know which ones are most critical to
address. Or, health leaders may believe their resources and capacity to address the health
consequences of other sectors are insufficient.
Yet, the failure of health policy-makers to become involved in intersectoral activities
designed to reduce poverty may actually increase the demands on the health care system.
Since poverty is a major contributor to disease and death, working with other sectors to reduce
poverty should help to lower the prevalence of illness among the poor, easing the burden on the
health care system. At the same time, raising the poor’s standard of living will make it easier
to treat disease, by ensuring that those who are sick have the basic prerequisites for recovery
food, adequate shelter, safe water, and a healthy environment. In recognition of this, WHO's
1
renewed Health for All policy stresses that in addition to developing sustainable health systems,
organized efforts to improve health require making health central to development by combatting
poverty and aligning sectoral policies for health (WHO, 1998).
The purposes of this paper are: 1) to stimulate national health policy-makers and advisers
in developing countries to consider the value of intersectoral action for poverty reduction as a
strategy for easing demands on limited health system resources, and 2) to provide guidance to
national health policy-makers and their advisers on how to set priorities among other sectors with
which to work in reducing poverty, so as to use limited resources most productively. Since the
links between health and development, and intersectoral action for health generally, have been
covered extensively in other WHO reports, this report focuses on the ’’analytic frameworks and
tools needed to move the field beyond a heavy reliance on anecdotal, descriptive accounts to
more quantitative indicators and results associated with health gains," as recommended by a
recent WHO conference (WHO, 1997a).
This report is organized into five sections. Following this introduction, Sectionlbriefly
reviews poverty characteristics and major causes of poverty in order to identify the potential
contribution of various sectors to its amelioration. Section 2 discusses methods for determining
the major causes of death and ill-health among the poor, which can also help point to specific
sectors for coordinated efforts at risk-reduction. Section 3 suggests a number of criteria for
setting priorities among various sectors and discusses how they can be used. Section 4 contains
specific examples of intersectoral programs or policies that have either reduced poverty or
improved the health of the poor specifically. Section 5 briefly discusses the biggest challenge
to intersectoral action: how to get the process started and keep it going.
2
X. POVERTY ASSESSMENT
In order to determine which strategies for poverty reduction are most appropriate to each
country, it is important to understand the characteristics of the poor, why they remain or become
poor, and the impact of various systems -- economic, political, cultural, social, etc. — on the poor.
Such information is essential for designing and targeting interventions, and it can also help in
monitoring progress.
1.1 Participatory poverty assessment
2: How to define poverty?
One of the most important sources of
information about the nature and causes of
poverty include NGOs which have direct
contact with the poor and poor
communities, and the poor themselves.
Qualitative sources of information, such as
participatory poverty assessments that
involve informal interviews with the poor,
may be especially helpful. These can
provide important insights into how the
poor cope with the effects of ill-health, and
what the poor regard as prerequisites in
gaining access to jobs, credit or capital,
health and social services, and political
participation. For example:
Poverty is defined in many ways. The World
Bank, other international donors and many
governments, usually define the poverty level
using income-based measures. But many would
argue that poverty encompasses a much broader
set of factors relating to basic human needs that
are not taken into account in simple income-based
measures. UNDP defines poverty as the ’’denial of
opportunities and choices most basic to human
development." Thus, poverty has social and
political dimensions as well. Furthermore, the
amelioration of poverty requires that certain
material aspects of living be provided, often as a
matter of basic human rights. This report does
not restrict the definition of poverty to income
alone. For a more detailed discussion of these and
other definitional issues, see the paper: Poverty
and Health: Who Lives, Who Dies, Who Cares?,
by M. Skold, published by WHO, ICO Division,
1998
A participatory poverty research study was recently undertaken in Pakistan. People in
low-income communities were asked to identify household characteristics that were more
common among the poor. In addition to those that lacked adult men or had a large
number of dependents, they cited those with sick or disabled adults unable to engage in
paid work and those with debt bondage to landowners, employers, or informal money
lenders. Powerlessness, helplessness, insecurity, absence of choice, and lack of faith in
official poverty alleviation programmes were also common factors among the poor. The
findings of the study compliment those of a quantitative poverty assessment undertaken
at the same time by the World Bank. (Wratten, E., 1995)
In a qualitative assessment of causes of poverty in Lesotho, those interviewed named
alcoholism as the most important single factor leading to poverty and poverty-related
3
conditions. Alcohol abuse was placed higher than unemployment, drought, hunger, or
laziness as a cause of poverty. (Sechaba Consultants, 1994)
1.2 Official poverty assessments
Poverty assessments have become a regular component of the World Bank’s process for
developing country assistance strategies and for determining the appropriateness of its loans. By
the end of Fiscal Year (FY) 95, 62 country-specific poverty assessments were completed,
covering 80 to 90 percent of the world's poor (World Bank, 1996). The Bank relies on household
surveys to develop their poverty profiles, supplemented by other data. They have also begun to
involve NGOs in the process and the poor themselves. The Bank’s poverty assessments not only
answer the questions about who is poor and why are they poor, but also examine the effect of
economy-wide policies and targeted interventions on the poor to look for ways to improve or
change them. They can be, and in some instances, are used to set cross-sectoral priorities. For
example:
In a group of 12 African countries, in the early 1990s, 84% of the poor lived in rural
areas and most were smallholders. Self-employment in agriculture is the predominant
occupation, with a large share of "income" being the food produced and consumed by
them and their families. Thus, efforts to promote growth in agriculture, and allow the
price of produce from rural farms to increase while ensuring that smallholders are able
to produce enough food to feed their families, are most important in these countries.
In Mexico, a poverty analysis found that public expenditures favoured better-off States;
as a result, loans support reforms aimed at equalizing spending across States and Bank
loans were targeted to the four poorest states to invest in physical infrastructure, and
improve basic education and health services. Because the study found that extremely
poor people could not take advantage of economic opportunities, the Bank financed a
health and nutrition project for the poorest groups. (Boer and Rooimans, 1994)
1.3 Enhancing poverty assessments for health
While official poverty assessments can be valuable in understanding the scope, nature,
and underlying causes of poverty, they may not address all the questions that health policy
makers might ask if they were determining where to invest their resources. For example, how
and to what extent does ill-health affect the ability of the poor to take advantage of expanding
economic opportunities? Are improvements in the availability or quality of education focused
on communities with the poorest birth outcomes? If loans are contingent on maintaining levels
4
of social and health expenditures by the public sector, or targeted to the poorest groups, how can
the health professionals be involved in facilitating or monitoring implementation progress at the
community level?
To address these questions, it is important to examine country-specific materials from a
variety of sources. A study of the interface between health and poverty in Bangladesh found
that the hard core poor had more morbidity than the moderate and non-poor. Because those
living in extreme poverty often have only their labour to generate income, protecting the health
of heads of households becomes a critical strategy for reducing poverty (Sen, 1997). Other UN
agencies, especially UNDP and UNICEF, as well as WHO can provide valuable information
about the characteristics of the poor, and the effectiveness of various economic and human
development projects in reducing poverty or reaching the poor. This is important for
distinguishing which socio-economic groups within each country benefit or are harmed by
current policies. For example:
UNDP and UNICEF reports indicate that since 1986, Viet Nam has made great strides
in reducing poverty. Still, income poverty remains high (20% using a nationally
determined level, 50% based on international comparisons). Remaining poverty is linked
to five key problems: geographic, linguistic and social isolation of ethnic minorities;
high exposure to risks such as typhoons, floods and illness; lack of access to productive
resources, particularly land and credit; unsustainable financial and environmental
conditions; and inadequate participation of people in planning and implementing
development programs. Efforts to reduce poverty, therefore, focus on land reform by
making more credit available, targeted rural infrastructure investments, and social
assistance for those left out of economic development. (UNDP, 1997)1
The Bank’s poverty assessment in Sri Lanka reported an increased incidence in malaria
and continuing undemutrition in young children. The report asserted that food stamps
target too broad a population to be effective, and need to be better targeted to the poorest
segments of society. Yet, the Bank does not address malaria, which contributes to slower
economic growth by lessening the strength and productivity of those who contract the
disease. WHO studies show that 90% of the global burden of malaria is attributable to
environmental factors (WHO, 1997b), but the Bank’s proposals do not address the
environmental consequences of economic growth. Thus, industrial development,
agricultural policies, or other environmental projects that allow malaria to increase might
be appropriate targets for intersectoral action.
1 This conclusion is consistent with the World Bank's 1995 Viet Nam poverty assessment, but
the Bank’s first priority is improving the incentive framework for savings and investment to sustain rapid
economic growth. (World Bank, 1995)
5
2. ASSESSING DETERMINANTS OF HEALTH AMONG THE POOR
In addition to understanding what contributes to persistent poverty, it is important to
identify the major determinants of health or illness among the poor. By considering which
strategies or interventions outside of the health care system can best prevent their spread or
development, opportunities for intersectoral action can be more clearly identified.
Identifying the key determinants of health among the poor at the national level can be
difficult in many developing countries. In part this is because of deficiencies in basic health
statistics and in cause of death data, which are characterised by under-registration and
misclassification of cause of death. Even when data are available, they often fail to distinguish
health status of different socioeconomic groups (WHO, 1996b). Assuming some data is available
for the country as a whole, five techniques are suggested to identify the underlying determinants
of health among the poor, or the impact of other sectors' development policies on the health of
the poor. These five are described in order of least to most data dependent, and are listed in
Table 1 along with the type of data needed to perform each one.
Table 1 Methods for determining key determinants of health problems of the poor
Analytic method
Data requirements
I 1. Grouping cause of death data into common
j riskfactors
■ Trend data on causes of death, from either vital
registration systems or special surveys
12. Analysing health and social indicators
i Poverty and educational levels from census data.
i together to identify those that fall behind
Safe water and sanitation coverage from census or
expected levels for countries at similar stages of sanitation records. Comparative data from Health,
; development
; Nutrition and Population Sector Strategy, World
; Bank, 1997 and World Health Report, WHO, 1997
j
f 3. Mapping health indicators and socioi economic disparities across regions within a
I country
\
I
j
\
; National surveys on income, educational levels and
; other important indicators of socio-economic status §
\ by province, district, or other regions. Health data
i (cause of death, illnesses, immunization levels, etc.);
: for same regions.
!
■:
14. Linking disease burden to poverty-related
j risk factors
s Data on causes of death, morbidity, and disability, |
distribution of selected risk factors, and measures of |
i exposure in the population to the risk factors.
Causes of death and disability may be estimated
; from epidemiological models of the cause of death.
I 5. Assessing effects of other sector
development policies/projects on health of the
poor
Epidemiological and economic studies that measure
\ the impact of various policies on health
{
'
6
|
2.1 Grouping causes of death into common risk factors
Data on causes of death for Figure 1
different years can reveal important
Distribution of Deaths by Cause
Among
the
Richest
and Poorest 20% of the Global Pop., 1990 Est.
information about poverty-related
illness. Are the major causes of
death primarily related to infectious
diseases?
Or, has economic
Richest 20%development begun to change the
major causes of death to those
related to chronic disease? Even
Poorest 20%where a country is undergoing
rapid economic growth, with
80
40
60
100
0
20
Parcantap* of Total Daath*
relatively steep drops in fertility
| Communicable,maternal, perinatal, nutritional diseases
and increases in life expectancies,
B Non-communicable diseases
I I Injuries
the overall cause of death profile
may still exhibit the disease
patterns of the least developed countries: communicable diseases, undemutrition, and high
maternal and infant mortality. See Figure 1. Since these diseases are more prevalent among the
poor, their prevention should continue to have high priority in most developing countries.
Although cause of death 3 Diseases of the poor and the rich ?
statistics commonly cite one
major cause, the poor rarely die
from a single cause of death as
poverty
and
malnutrition
contribute to many diseases.
Thus, it may be better to group
mortality data in broad
categories that relate to
underlying risks, rather than
specific disease categories. This
way of examining mortality data
can promote an intersectoral
view of risk reduction. For
example, programs designed to
address
an
underlying
contributor to poverty (e.g.
education) will probably help to
One should use some caution in making inferences about the
extent to which certain diseases are concentrated in the poor.
For example, the spread of HIV-AIDS is changing the
traditional connection between poverty and infectious
diseases. While those in lower socioeconomic groups may be
more vulnerable to the virus and to death from it, HIV/AIDS
cuts across all socioeconomic groups. Another example is
environmental health risks. In the least developed countries,
these risks continue to be the "traditional” ones, such as
unsafe food and drinking water, inadequate sanitation, and
poor housing, which disproportionately affect the poor. But
as a country progresses in its economic development, the
more "modem" environmental risks, such as air pollution,
chemical exposures and traffic accidents, can rise rapidly.
These latter risks do not limit themselves to any particular
class or income group, though they may disproportionately
affect the poor in certain situations. As countries develop
economically, differences in health status by socio-economic
status will change.
7
stem the spread of communicable diseases in poor communities, and make it more likely that
parents will bring their children to be vaccinated.
Identification of underlying risk factors relies on basic knowledge about epidemiology
of diseases; such information has been comprehensively summarized (Jamison, Mosley, et
al., 1993). Then, one has to link these underlying, or proximate, causes to various sectors that
may contribute to their reduction. For example, one study identified the key proximate
determinants of child survival in developing countries as: a) maternal risk factors such as
educational status, b) nutrition and diet, c) the physical environment, d) injury, and e) personal
illness control (i.e. health seeking behaviour and health care provision) (Mosley and Chen, 1984).
These would point to interventions by the education sector, the agriculture and food security
sectors, environment and public works sector, and possibly the transportation and energy sectors
that contribute to injuries, respectively. Risk factors common to several clusters of causes of
death would attain a higher priority in this approach. If one could reduce malnutrition, for
example, childhood communicable diseases would decline and pregnancy outcomes would
improve.
2.2 Analysis of key health and socio-economic indicators
Another method for identifying the major determinants of health among the poor involves
analysing some key indicators as an interrelated group - health status, education, and income.
By comparing these indicators with those of a similar group of countries in the same region, or
at similar levels of average per capita income, the indicators that are lagging behind point to
priority areas for attention. (Gunatilleke, 1995 and WHO, SEARO, 1997c) In other words, by
looking for irregularities in the simultaneous upward movement of key indicators, problems and
avenues for action are more readily identified. The "laggard” indicators "becomes the trigger to
renew the process of poverty alleviation.” For example:
Sri Lanka has high life expectancy and high levels of female literacy for countries with
the same or even higher per capita income, due largely to a long history of welfare
programmes, education for girls, and universally accessible maternal and child health
care services.. But it has more child malnutrition and higher rates of poverty compared
to others in the region. This suggests that a better balance between social and health
programs, and those that promote income-generating capacity and employment, might
be able to address the continuing problems with child malnutrition.
Thailand, by contrast, has three times the per capita income of Sri Lanka, but lower life
expectancy and higher infant and maternal mortality rates. Even though its
8
macroeconomic policies have promoted high rates of macroeconomic growth, its policies
and interventions have not been implemented to ensure development and growth that are
"poor friendly". In the wake of the recent economic crisis in Asia, poor workers who
migrated to the city for jobs are among those who will hurt the most. (IHT, 1997) The
failure of Thailand and many other Asian countries to invest in social security systems
is likely to affect the health of the poor over the next decade.
For countries with high mortality, high fertility, and low female literacy, the most
important interventions might be enrollment of girls and women in education, improved
accessibility of reproductive health services, and more equal distribution of income-earning
assets (land, credit, equipment). In situations of high literacy and high fertility, greater emphasis
on disseminating information about reproductive options and making employment opportunities
available to women may be more appropriate. High social indicators (educational status, low
fertility rates) combined with continued high levels of poverty, unemployment and
undemutrition, suggest that it is important to focus on efforts that enhance the income-earning
capacity of poor households, in addition to nutrition and health programs. Where such data is
available on a sub-national basis, one could perform a similar analysis to identify areas of the
country where certain areas need more emphasis.
2.3 Sub-national "Mapping" of health disparities
To compensate for the fact that few developing countries have data on health status
disaggregated by income or other indicators of poverty, analysis of differences in health status
across regions within a country may provide some clues about key health problems affecting the
poor. When regional cause of death data is compared to more general socio-economic indicators
by region, the health problems of the poorest regions should point to health problems among the
poor that deserve focus. For example, some national surveys collect data on incomes,
educational levels, housing conditions, nutritional status, and other important indicators of socio
economic status by province and districts (e.g. Zimbabwe, Sri Lanka), Countries may even
have such information disaggregated for even smaller census tracts, postal zip codes, or
neighbourhoods, which can be very useful for identifying which local communities are in
greatest need. If health statistics are available for the same geographic areas, the comparison
of health problems in areas with lower socio-economic indicators can reveal much about health
issues affecting the poor. Recent country-specific or city-specific examples of this type of
analysis include:
South Africa. Analysis of data at the provincial level showed "higher mortality rates and
lower life expectancies in the poorer provinces..Due to the unavailability of similar
9
data at the magisterial (lower) level, a similar analysis could not be performed for local
communities. However, for at least some magisterial districts where data was obtained,
it found a "higher percentage of deaths due to infectious and parasitic illness . . .in the
poorer quintiles [of magisterial districts]."(McIntyre, 1997)
Zimbabwe - The WHO-SIDA Initiative on Equity in Health and Health Care analysed
data from a 1995 Poverty Assessment Survey. It showed the distribution of poverty by
province, by type of area (commune, small-scale commercial farms and resettlement
areas, large-scale commercial farms, and urban areas) and by districts within the
provinces. Health status and health care utilization indicators were available at that level
from 1982 and 1992 Censuses, and 1988 and 1994 Demographic and Health Surveys.
The analysis showed wide geographical disparities in certain illnesses. (Chandiwana, et.
al., 1997)
A study of death rates among people living in different socio-environmental conditions
in Accra, Ghana, and Sao Paolo, Brazil found age-adjusted death rates up to 3 times
higher in the most disadvantaged areas of the metropolitan communities. It found that
the poor not only die more from infectious diseases affecting children, but also from
certain diseases affecting adults (e.g. circulatory and respiratory diseases). (Stephens,
et.al., 1997) The latter finding may be due to misclassification of causes of death among
the poor, for whom ill-defined causes were often ascribed to "heart failure".
2.4 Attributing disease burden to risk factors associated with poverty
One disadvantage of using cause of death data alone is that the prevalence of illness and
disability from injuries or disease is not taken into account. The development of ’’composite
indicators’’, such as quality-adjusted life years (QALYs) and disability-adjusted life years
(DALYs), overcomes this problem by combining mortality and morbidity into one measure,
sometimes referred to as disease burden. This type of analysis can reveal very different patterns
of illness than mortality alone, and as a consequence, point to a set of causes that suggest other
sectors which might be involved in their amelioration. In developing countries generally, the
greatest share of mortality, morbidity, and disability is due to inadequate water and sanitation and
undemutrition (Murray and Lopez, 1996). But depending on the development stage of each
country, and unique economic, political or social factors, the profile may be different. For
example:
A disease burden analysis was recently performed in South Africa, which showed that
in 1990, the major causes of potential years of life lost (due to death) were accidents,
10
poisoning and violence (22% of potential years of life lost), followed by perinatal
conditions (17%), and infectious diseases (15%). According to the authors of the study,
the underlying conditions that contributed to such deaths included: poverty,
unemployment, overcrowded or inadequate housing, and inadequate access to primary
care services. (Bourne, D., 1994)
A burden of disease analysis in Indonesia, revealed a "double burden" pattern of disease,
in which infectious diseases related to poverty and underdevelopment co-exist with
chronic and degenerative conditions of a growing middle and upper class. A DALYbased analysis showed that the five diseases that contributed most to productive years of
life lost were, in descending order of magnitude: pneumonia, pulmonary TB, intestinal
infectious diseases, neoplasms, injuries. (Kosen, S., 1996) By contrast, main causes of
death were: infectious diseases, cardiovascular disorders, perinatal problems, injuries,
and neoplasms. Burden of disease data suggest a need to begin shifting more resources
towards prevention and treatment of respiratory infectious disease, via smoking reduction
efforts and pollution control.
Performing such analyses in most developing countries, however, is very difficult since
morbidity information is often unavailable. Estimates can be derived by extrapolating trends in
disease burden calculated from surveys in cities or communities to other countries in the same
region (Murray and Lopez, 1996). But the assumptions built into these models can introduce
substantial uncertainty about the resulting estimates.
If disease burden data expressed in QALYs, DALYs, or other composite measures is
available for a country, however, they can be linked to underlying risk factors. Sectors that can
help to ameliorate those risk factors that disproportionately affect the poor would become the
focus for possible intersectoral actions for health. For example, a study linked Sub-Saharan
Africa's disease burden to underlying determinants of health that roughly corresponded to various
sectors (Yach, 1997). See Table 2. It emphasizes the importance of addressing malnutrition,
which accounted for 32.7% of the total disease burden in the region, suggesting that a focus on
the agricultural sector and food security is especially important.
11
Table 2: Sectoral burden of disease, by percent (%) of total DALYs
DETERMINANTS
Sub-Saharan Africa
Established market
economies
World
In non-health sectors
70.5
53.1
49.6
Water and sanitation
10.1
0.1
6.8
Food/diet
— ovemutrition
— undemutrition
1.0
32.7
13.0
0.0
4.5
15.9
Behaviour
9.7
26.4
10.2
Transport
1.9
4.4
2.5
Energy
1.4
0.7
1.4
Occupational
1.7
5.3
3.2
Violence
2.4
3.2
2.6
Rural development (malaria)
9.6
0.0
2.5
Health services
— Eradicable
— Immunizable
— Treatable
17.2
1.0
8.3
7.9
12.6
0.0
0.1
12.6
14.9
0.6
4.1
10.2
TotalDALYs (thousands)
295,294
98,794
1,379,238
Source: (Yach, 1997)
2.5 Health impact assessments of development projects
Often, it is not enough to examine recent data on causes of death and illness, since new
risks to health may arise quickly as a result of particular development activities. Thus, it is
important to assess the health impact of development projects. One of the most thorough reviews
of the quality of evidence regarding the impact of other sectors' development policies on health
paid particular attention to effects on the poor. (Cooper Weil, et.al., 1990) Since that work was
so comprehensive, it is strongly recommended as a starting point for health impact assessments.
However, that study did not provide exact quantitative relationships between general types of
development activity and health which could be used to gauge the expected impacts elsewhere.
This is because the activities studied were project-specific which makes it hard to generalize the
findings, or the links between some sectors (especially macroeconomic policies) and health are
so numerous and complex, that one cannot prove direct causality.
12
If one were to undertake country-specific health impact studies of development policies,
some research can provide a good starting point. For example, for a set of diseases related to
’’poor household environments”, such as TB, diarrhoea, and respiratory infections, one study
estimated the reduction in global disease burden that could be achieved through improved
sanitation, housing, and water supply, or wider use of less polluting heating and cooking fuels
(World Bank, 1993, p.90). But because there are so many development policies that have health
impacts, and within each sector, several activities that may be of particular importance to the
poor, it is important to select which policies or projects should be studied further. Then, experts
from various fields can be asked to study specific aspects of the proposed policies. Their
findings must then be synthesized to help policy-makers understand the health impacts of
previous development policies, or the potential health implications of proposed policies, so that
those with the greatest risk to health or the greatest potential contribution to health can be
identified.
13
3. SETTING PRIORITIES AMONG SECTORS
Once the major contributors to poverty and the major causes of death or illness among
the poor have been identified, one is likely to have identified numerous underlying problems:
poor sanitation and unsafe water, low educational levels among women, malnutrition, inadequate
housing, unemployment or lack of income, poor land productivity, or hazardous working
conditions. This suggests that the sectors one could involve in intersectoral action are many:
environment, water supply, agriculture, education, training, housing, industry, finance and credit,
and even the media. With so many potential sectors to involve and limited resources and time
available, how can one select the most important?
In general, the choice of appropriate sectors for health policy-makers to involve should
be based on those that present the greatest risks to health or are most likely to improve health
status. And, since poverty reduction is an equally important goal, the choice should be based on
those that can reduce poverty most effectively. However, as noted, in many developing countries,
it is very difficult to measure the health risks associated with each sector, and equally hard to
assess the potential contribution that each sector could make to health improvement and poverty
reduction. Furthermore, the realities of most low-income countries, such as very scarce
resources, political uncertainty, and donor pressures may limit the range of choices that can be
considered for potential intersectoral action (Baah, 1995).
Due to these difficulties, a range of decision-making criteria are suggested from which
policy advisers and policy-makers can pick that go across a continuum, shown in Figure 2 on the
next page. Displayed from less to more data-dependent, the criteria fall into three sets:
1) those that are based on social or political values, or on donors’ priorities; 2) those based on
qualitative assessments of impact; and 3) those that use quantitative data to estimate disease
burden avoided, or an economic comparison of the benefits of various interventions. Criteria that
depend on quantitative data are not necessarily value-free, as most data analysis methods involve
value-based assumptions and judgment is still required in whether and how to apply the results.
After explaining these criteria, suggestions for how to use these criteria to actually set priorities
are discussed.
14
FIGURE 2
CONTINUUM OF CRITERIA FOR SETTING PRIORITIES AMONG OTHER SECTORS FOR INTERSECTORAL ACTION
(Quantitative estimates of health impact)
(Social/political values)
Political Relations with
factors other ministries
Opinions of
the poor
Linking risk factors
to sectors
Priorities of
other donors
Multi-sectoral
cost-effectiveness analysis
I
Primary economic
activities of the poor
Direct
Direct impacts
impacts
health
ononhealth
Improve the poor’s
health stock
(Qualitative determination of health impacts)
More data-dependent-4
♦-Less data-dependent.
15
3.1 What the poor regard as most important to their health
The poor themselves may be among the most important informants when it comes to
decisions about which sectors need to be involved in improving their health and ending the cycle
of poverty. For example, in a Participatory Poverty Assessment conducted by the World Bank
in Zambia in 1994, after health care, poor people’s highest priorities for assistance included allweather roads, for marketing purposes as well as increasing access to clinics and hospitals during
the rains, suggesting the need for collaboration with the transportation sector. One caution,
however, is that if the poor have uninformed opinions about the health risks of various activities,
the results may be less useful than if they had more complete information about the actual risks.
3.2 Ministries with which you are on good terms
Clearly, cooperation from other sectors is critical to the successful implementation of any
joint activity. Thus, it is worth considering which other sectors have close ties with the Ministry
of Health, as a result of previous successful efforts due to overlapping jurisdictional boundaries
at the local level or simply good relationships between the ministers. But this has significant
risks. Ministers change often and their tenures may be shorter than the intended intersectoral
projects. If a project is too closely associated with the ministers and one or the other leaves, the
project itself may lose the support of whomever replaces the ministers. This problem may be
minimized by developing intersectoral committees or groups at all levels of the Ministry (from
national to district to local), but the risk is still there.
3.3 Political factors
If there are a number of development activities that might represent good investments,
the decision about which sector(s) to collaborate with might rest on which other ministries have
more political power. For example, if the Ministry of Agriculture is very powerful, collaborating
with it to ensure that food subsidies are properly targeted and result in better nutrition might
increase the chances for support from the Ministry of Agriculture for extra resources to be
allocated to the Ministry of Health to provide health and nutrition education. Or, since the
Ministry of Trade is often very influential, a joint project to ensure that trade policies take into
account health impacts, may be very fruitful.
3.4 Priorities of donors
In developing countries, much of the development agenda is driven by external donors.
16
If country officials believe that they have little power to change existing priorities as determined
by external donors, or if they agree with the existing priorities, the projects that are receiving
priority attention by those donors, which tend to be sector-specific, may be the most appropriate
ones for intersectoral action.
3.5 Distributional impact on the poor’s health ’’stock”
Some analysts suggest the importance of looking at activities that correspond to the
notion of health-related capital or health-promotive assets, such as an educated society (which
would point to the education sector), safe water supply and sanitation (which suggests the public
works sector), transportation and housing, each of which correspond to specific sectors. Others
extend the notion of health-related capital further to define contributors to individuals' health
"stock", which include food intake, health care services, health behaviour, and exogenous
environmental conditions (Anand and Chen, 1996). Since the poor and disadvantaged will
typically have lower individual health stock or reserves, it becomes critical to examine policies
(economic, development, social, etc.) in those sectors that will have a disproportionate impact both negative and positive - on the poor's intake of food, on their health behaviours, or on their
physical environment.
3.6 Distributional impacts on economic activity of the poor
One could also examine sectors that affect the largest area of economic activity in which
the poor are engaged. For example, in many developing countries, between 60 to 85 percent of
all workers are employed in agriculture, small industries, or other small enterprises. Thus, while
large factories or mines may be a highly visible or growing sector of the overall economy, they
would not employ the majority of the population, or the majority of the poor. Assessment of
occupational health hazards, for example, would be better targeted to those arising from changes
in agricultural policies than to those in large-scale industries. This was the case in Guatemala,
where the health and welfare of migrant Indian workers were the focus of intersectoral efforts
amongst health, social security, and agricultural sectors. Since the dominant economic activity
varies by region within countries, local intersectoral actions might also differ accordingly.
3.7 Direct impacts on health
Some analysts argue that the domains for health priorities should be limited to those that
have direct effects on the health of the poor (Bobadilla, 1996). In other words, educational
17
programs alone might not constitute a health priority, but health education programs within the
schools would. Or, activities that generate income unrelated to health might be considered
outside the scope of influence of the health system, whereas programs that seek to train
community health workers to give indigenous people a source of income might be within the
range of options. Within particular sectors, the principle of aiming for direct health impacts can
also be applied. For example, within the agricultural sector, activities that directly contribute to
improved nutritional status, that minimize human exposure to harmful pesticides, or that focus
on malaria control, might be the most appropriate targets.
3.8 Multi-sectoral balance sheets
Another way to select other sectors for collaborative action involves quantifying both the
amount of disease burden (as described in Section 2.4) and the potential contribution to health
attributable to each sector. One would then combine the two sets of data into a ’’multi-sectoral
balance sheet", which would show each sector their positive or negative impact on health (Yach,
1997). As noted, it is very difficult to compile all the data needed to compile such balance
sheets on a country-specific basis. Still, if one has basic information about the direction and
relative degree of harm or potential good that can come of activities by other sectors, the balance
sheet approach may have merit in making more informed decisions. It is important to note,
however, that the use of QALYs or DALYs for allocating resources has been discouraged by a
WHO Working Group based on methodological problems that result in inequities (WHO, 1995).
3.9 Multi-sectoral cost-effectiveness (CE) comparisons
One of the drawbacks to the “balance sheet” approach is that it does not take into account
the costs of implementing various activities. As such, does not reflect the advantages of
investing in activities that provide the most gain for the same cost. But, "if a government is
motivated to improve child health in its population, it will help to be able to compare the relative
cost-effectiveness of investing in girls' education, making specific infrastructure improvements,
introducing food pricing policies, and school health programmes." (WHO, 1996a) Since
resources are always limited, an alternative decision criterion might be the economic costs of
each approach. The choice of activities for intersectoral action could thus be made based on
which are most cost-effective, expressed in cost per health “impact” (e.g. death averted or illness
avoided).
There are several problems with this criterion. First, there are few cross-cutting,
intersectoral comparisons of the effects of various interventions on health outcomes, generally
18
and among the poor. One study examined
the marginal contribution of nutritional
programs, medical care, maternal education,
and job creation to the control of Vitamin A
deficiency among children in Nepal.
found
that
health
interventions
It
were
effective but, "they were secondary to
community development characteristics [e.g.
roads], agricultural patterns [e.g. having a
home
garden,
growing
pulses],
the
nutritional status of children, and the overall
sanitation level of the ward." (Tilden, et.al.,
1994) However, it did not compare the costs
of these interventions. A second problem
relates to the difficulty in choosing a single
health indicator for comparing the cost
effectiveness of cross-sectoral interventions,
and the likelihood that in practice, it is the
combination of interventions that make a
4 Limits to Cross-Sectoral CE Analysis
The relative scarcity of multi-sectoral cost
effectiveness (CE) studies relates in part to
problems in deciding on one effectiveness
measure that allows for intersectoral
comparisons. “If one is simply assessing the
relative attractiveness of alternative means for
achieving a single, specific health objective — for
example, reducing infant mortality — this
measurement problem disappears, and one can
judge intervention cost-effectiveness simply in
terms of, say, cost per infant death averted.”
(Jamison, 1993, note 9) In the real world,
however, interventions will have effects on
several health conditions.
Even for one
overriding problem such as infant mortality, the
practical question is: Which mix of interventions
is most appropriate? Cost-effectiveness criterion
is not particularly useful in such situations. It can
help to ensure each element of the intervention
mix is effective, but rarely can it analyse the
overall impact of several complementary
interventions.
difference (see Box 4). Furthermore, cost
effectiveness studies often fail to consider
that the costs of various interventions are borne by different sectors of society. It may be more
cost-effective to provide water and sanitation, but if consumers are required to pay for these
services, the result will be inequitable to the poor.
An analysis performed for the World Bank’s 1993 World Development Report compared
47 health interventions based on their CE ratios (the ratio of unit cost of a DALY). While all of
interventions were health or health-related, the report recognized that "for some [non-health]
interventions (for example, family planning and girls schooling), the cost per DALY is
sufficiently low to make them attractive on health grounds alone; other benefits [such as
increased income and status later in life] only strengthen the case." This points to a potentially
serious drawback to making decisions based on DALY and similar indicators. "If mother's
education, or improving water supply and sanitation conditions, generate a bigger "bang for the
buck", then the health budget should be redirected to the Ministry of Education, or of public
utilities." (Anand and Hanson, 1997) This implication would be difficult for most health
advocates to accept.
19
3.10 Using the criteria to set priorities
Priority-setting in health care is not usually applied to allocation of health resources (time
and money) amongst other sectors. It is far more commonly applied to choices in allocating
health resources within the health care system itself -- between different levels of care or types
of services or geographic regions of a country. However, the basic process of priority setting is
the same regardless of what is being prioritized: the importance attached to various activities by
all relevant stakeholders — government, the public and the poor in particular, private sector
institutions and organizations — must be reconciled. Rather than relying on political influence
alone, the approach recommended is to provide all stakeholders with evidence on health needs
and effectiveness of various interventions
to ensure that their opinions are based on
factual information.
Clearly, priority
setting will always be a political process.
But, conflicts among stakeholders can be
mediated by information and technical
input about the actions most likely to
achieve the intended outcomes, or those
that are more effective in doing so. "At
the very least, sound policy analysis
places limits on the discretion of decision
makers who have to consider the costs of
ignoring the available data."
(Frenk,
1995)
The planning or policy analysis
unit of the Ministry of Health has an
important role to play in gathering and
analysing
the
information
5 Data synthesis and presentation tips
Several techniques can help to synthesize large
and complex information for busy decision
makers. One approach involves showing each
sector's impact on health in the "balance sheet"
approach described previously, in order to display
the relative degree of estimated harm and
potential contribution to health of each sector.
Another approach is to display the determinants
of health in a type of "visual health information
profile" which graphically shows the difference
between current performance and agreed upon
goals, for example, the current proportion of the
population with access to safe water and
sanitation versus the proportion established in as
a national goal in a five-year plan. Geographic
Information System (GIS) mapping tools may
also be used, if sufficient information is available,
to see how villages compare with respect to
access to basic services, such as safe water
sources, schools and health facilities, or
proximity to industrial sources of pollution.
described
earlier -- the causes of poverty, major
morbidity and mortality among the poor, effects of other sectors on health status, effectiveness
of various interventions in improving health status, and the development priorities within other
sectors. Then, the challenge is to assemble and present this information in a manner that is clear
and understandable to decision-makers. See Box 5. These and other tools are essential to help
busy decision-makers synthesize large amounts of information, and quickly understand how
activities they are asked to prioritize were identified.
All stakeholders that can contribute to poverty reduction and health improvement of the
poor should be involved in reaching consensus on which criteria to use to make choices among
20
potential intersectoral activities. They can propose other criteria that might be added to those that
will be used to make the choices, such as improved equity in access to economic opportunity.
As a practical matter, the lack of country-specific "hard" data on disease burden or cost
effectiveness of various interventions in the poorest countries suggests that the criteria chosen
will rely more on social and political values. But if regional information is available, it might
be used to alert policy-makers to issues that would influence their decision if country-specific
analyses were available.
The final step is to rate proposed intersectoral activities on the basis of the degree to
which they meet the criteria that are chosen. This can be judged by an existing intersectoral
committee of various ministries or a special advisory group that includes non-governmental
representatives, or by using a Delphi technique2. Involvement of representatives from other
ministries and from NGOs in selecting the criteria and rating the options against them not only
enhances the transparency of the decision-making process, but builds political support for the
actions that are subsequently chosen.
2 The Delphi technique is a decision-making method that seeks consensus through consultation
with experts, when adequate hard data is lacking. Experts are given all relevant information and asked
to make a choice. Their opinions are consolidated and relayed back to others in the group. Group
members can then modify their decision on the basis of other members' opinions, until consensus is
reached.
21
HE-'OQ
>•
I ( o°
V
■■
4. INTERSECTORAL ACTION FOR HEALTH - CASE EXAMPLES
The most effective poverty reduction strategies include both labour-intensive economic
growth and human development investments (Boer and Rooimans, 1994). While numerous
countries' development plans reflect this fundamental lesson, it is less common to find projects
that combine such approaches within the same setting where a coordinated strategy might have
even more impact on the poorest populations. This section highlights poverty-reduction projects
or policies that have had both a health component and at least one other component, from either
economic growth or human development strategies. It features many projects that have
demonstrated improved health status of the poor, or that have targeted the poorest groups, in
order to have maximum impact.
Because of the wide range of development activities, this section discusses a selected set
of sectors and their associated development activities. The five selected for this review were
based on their significance to economic growth and to health status improvements as suggested
in previous sections: 1) community and microenterprise economic development;
2) agriculture and food policies, 3) education policies, 4) macroeconomic policies, and
5) environment or infrastructure investments to improve the supply of safe water and basic
sanitation. This selection does not imply that other sectors are unimportant, but rather that a
limited number of areas could be covered here.
Common to all these strategies is the need to design programmes to reduce structural,
cultural, and political barriers that often impede the poor from taking advantage of opportunities
for economic, health, and social improvement. This implies that all poverty reduction efforts
must strive to distribute benefits equitably based on communities most in need (Gunatilleke,
1995) . Methods for identifying the poorest communities within districts or sub-regions of a
country should be used to decide where to locate projects, as WHO's Division of Intensified
Cooperation with Countries in Greatest Need has encouraged with health service programs in
Bangladesh (WHO, 1997e, draft) and health insurance programs in Vietnam (Ron and Carrin,
1996) . In addition, the reality of poor households must be taken into account by ensuring, for
example, that they do not bear extra costs for transportation to programs. A related WHO-ICO
document Poverty and Health: Who Lives, Who Dies, Who Cares'? discusses these issues in more
detail.
4.1 Microenterprise development and community economic development
Community and individual economic development activities encompass a range of
programs that improve the income-generating capacity of the poor. Microenterprise development
22
focuses more on the individual, and includes financial services (credit schemes), training in
marketing and accounting, and solidarity groups that serve purposes of providing loan collateral
and social support (Rodriguez-Garcia, Macinko, and Waters, et. al., 1996). Community
economic development, focuses more on the entire community be it a poor rural village or an
urban slum neighborhood, and involves the creation of community-owned, cooperativelymanaged enterprises that strive improve community welfare.
Microcredit and health. Incorporating health-directed activities into credit schemes can
improve their health ’’capital” which strengthens the ability of creditors to repay loans, and
increases their earnings potential. Some detractors challenge the notion of combining health or
social services with credit/savings services by arguing that loan defaulters might be cut off from
the health or social service program and its benefits. If they are not cut off, then it reduces
incentives for loan repayment. A compromise may be a “piggyback” approach which allows a
social or health organization to provide services to the existing networks of credit groups.
Examples of such programs in the field include:
The Grameen Bank in Bangladesh, which serves more than two million people (94% are
women) provides loans to self-employed people, about half of whom “graduate” from
poverty after 8 successive loans. The Bank offers emergency health loans, but because
ill-health is the single largest cause of loan default, a pilot health program was developed
in 1994-95 for both members and non-members in 7 areas. Operating like a prepaid
health plan, the program charges $ 1.25 (USD) per year in advance for all family members
to receive a range of health services. (Khairul Islam, 1996)
Freedom from Hunger (a US-based NGO) developed a “Credit with Education” program
that currently operates in 7 countries (Bolivia, Burkina Faso, Ghana, Honduras, Mali,
Thailand and Togo). In most countries, the organization develops partnerships with
financial institutions that provide credit to women in poor, rural areas. Field agents hold
educational sessions on breastfeeding, infant and child feeding practices, diarrhoea
prevention and management, family planning, and immunizations. The cost of the
sessions is covered by the interest borrowers pay for their loans. Evaluations found that
relative to comparison groups, women participants were more likely to practice a number
of health/nutrition behaviors promoted by the program. Young children of participants
had better diets than non-participants (MkNelly, 1996).
Community economic development and health.
Some economic or industrial
development projects have explicitly recognized that the health of people in the community is
essential to the success of local development efforts. For example:
The Population and Community Development Association (PDA), an NGO in Thailand,
23
has convinced more than 85 private companies to "adopt” rural villages by providing
seed funds for industrial or agricultural projects (e.g. shoe factories, gem-polishing,
gardening cooperatives) and training for community members in project management.
These efforts are linked to health-related PDA activities such as community gardens,
irrigation projects and environmental education programs. Because of the growing
prevalence of HIV/AIDS infection, many of the projects now allow workers who become
infected to do piecework at home so that they can continue to earn money. (Viravaidya
and Sacks, 1997).
The Gonosasthya Kendra (GK) health care system in Savar, near Dhaka, Bangladesh
provides health care through a system of subcentres and a 70 bed referral hospital for
about 165,000 persons. In addition, it runs vocational training programs for women and
handicapped persons, and provides small loans to over 2,000 poor families.
4.2 Agriculture and food policy
Several types of agricultural policies have particular significance for poverty reduction
and health: land reforms, irrigation and pesticide projects, food subsidies, and efforts to tie
agricultural productivity to nutrition. Land reforms include land redistribution that gives the
poor greater access to arable land, tenancy reform involving changes in the way land is leased
or sold so as to make it easier for the poor to make payments and retain profits from crop
surpluses, as well as land titling.
Land reform has been cited as a major factor contributing to Kerala State, India's
impressive health and social indicators. In 1969, 1.5 million tenants received full title
to the rice fields they worked, the household compound land, or both. Tenants who
received rice paddies were able to produce about half of their families' basic food
requirements. Land reform did not protect the poor from declining prices, nor did it give
them access to capital to convert their land to more profitable uses. But, by removing the
threat of eviction, tenants had more incentive to engage in political processes related to
community development (Franke and Chasin, 1992) Slum dwellers in Brazil and Lima,
Peru who were given land rights also showed greater participation in community efforts
designed to improve neighborhood health and educational facilities (Harpham and
Stephens, 1992, p. 115).3
3 Land rights and allocation of land for various purposes involves various competing purposes:
domestic and cash crops, forestry, industrial development, infrastructure, energy development, etc. These
competing interests must be weighed against each other, as well as against the health and environment
24
Disease prevention measures have been incorporated into irrigation schemes. For
instance, the Government of Mexico, fearing the effects of spreading cholera throughout Latin
America, prohibited the use of sewage water for irrigating fruit and vegetables. As a result, the
average number of diarrhoeal episodes among under-5 year olds decreased from 4.5 to 2.2 in the
next two years. If not proper designed, irrigation schemes can increase the probability of
schistosomiasis and malaria, indicating the need for health professionals to be involved in the
design of water resources development.4
Food subsidies targeted to the poor can direct subsidies to those regions with the greatest
concentration of the poor. They can also be pegged to a basic or rationed set of foods, take the
form of food stamps in which vouchers for the poor can be cashed in for specific food items, or
free food can be distributed directly to the poor through schools, health centers, etc. For
example:
A study conducted by Indonesia's Directorate General of Community Health, in
collaboration with the National Institute of Health Research and Development and Bogor
Agriculture Institute showed that most school children in poor villages were suffering
from insufficient caloric intake. The children often went without breakfast, affecting
school performance. In 1996, the government has launched a national program to
provide supplementary food for school children, focusing on poor villages.
Efforts to tie agriculture productivity improvements to nutrition include policies that
a) encourage substitution for crops that harm health and b) ensure the production of safe and
sufficient foods. For example:
A WHO study in the early 1980s examined the interaction between changes in health
status and development processes in countries with low per capita incomes, but high
health and social indicators, e.g. Sri Lanka and Costa Rica. The agricultural policies
that contributed most to improved nutritional status were those that increased
productivity in the agricultural sector, those that encouraged diversification, those that
increased access by the poor to credit, and those that promoted land equity . When
incentives for production were combined with food subsidies, they produced steady
increase in both agricultural output and nutritional status (WHO, 1986).
impacts that result from reallocation and redistribution of land.
4 See Hunter, J. et.al., 1993. Parasitic Diseases in Water Resources Development: The Need
for Intersectoral Negotiation, WHO, for technical measures that can control malaria, schistosomiasis,
and lymphatic filariasis in water development projects. It also proposes financing strategies and contains
practical advise on how to negotiate effectively with other sectors.
25
4.3 Education policies
The equation is remarkably simple: greater education attainment translates into improved
health status. Investment in the education of girls had a particularly high pay-off; girls who have
some education are more likely to delay childbearing, have better pregnancy outcomes, have
fewer children, and have more healthy children than those with less or no education. The World
Bank found that in Africa, increasing literacy among women and girls by 10% could lower infant
mortality by an equal proportion (World Bank, 1993). Three years of education (particularly for
women) is associated with a 20-30% decline in the mortality of children under age 5 (World
Bank, 1992b).
To complement these long-term strategies, education sector initiatives directly relating
to health are quicker ways of influencing the health of the poor. School programs for health care,
nutrition, the monitoring of health and immunization, health education at an early age, and the
promotion of habits, attitudes and practices conducive to health, have formed parts of national
strategies in many countries. School health programs include: teaching health education in the
schools; providing health services and nutritional supplements in schools, especially those with
higher concentrations of poor children; marketing health insurance through the schools as in
Vietnam (Ron and Carrin, 1996), improving the health environment of the school (water,
sanitation, minimizing exposure to harmful substances).
Egypt has a comprehensive approach to school health, based on the belief that education
is "the vehicle of preventive medicine". The Ministry of Education has the lead for a
program that includes school nutrition, particularly in rural areas, regular medical check
ups for children, comprehensive health insurance for schoolchildren, healthy
environments for schools, health education in the curriculum, and summer health clubs.
(Bahaa El-Din, 1998).
Thailand's success in reducing undemutrition was based largely on a coordinated
strategy with the education system. Nutrition education and encouragement of
breastfeeding were combined with food supplements. School lunch programmes were
established in 5,000 schools and community education programs promoted home
gardening, fruit trees, and fish ponds. Pre-school children were weighed and checked
every three months. (UNDP, 1997) More recently, the Prime Minister required health
and education ministries to institute a far-reaching AIDS education program.
4.4 Macroeconomic policies
Clearly, many aspects of macroeconomic policy and structural adjustment have an impact
on health, but research on the effects of such policies (individually and in combination) has
26
produced inconsistent results. Some studies suggest that economic growth has provided the
means by which social conditions and health status have improved. Others have found that
standard structural adjustment program changes (e.g. reductions in public expenditures, price
reforms, wage restraints, trade liberalization) have worsened many social problems and
contributed to declining health status, particularly among the poor.
There are several reasons for these mixed results. Some macroeconomic changes have
delayed effects; for example, clean water supplies and sanitary conditions do not deteriorate
immediate following a recession and while food intake may decrease, nutritional status may
decline more slowly (Carrin, Jancloes and Ajay, 1993). In addition, most studies to date do not
show how macroeconomic policies affect the determinants of health status that are not within the
health system (Anand and Chen, 1996). Thus, to fully understand the effects of macroeconomic
policies on health, particularly that of poor populations, such studies must also consider how they
affect determinants of health outside the health system.
The creation of social emergency funds in several Latin American countries hints at the
impact they can have. Such funds have helped to cushion the expected adverse effects
of economic restructuring and have been used to fund a variety of social services, most
of which have direct or indirect effects on health. These include education, sanitation and
rural development programs, in addition to health care services. In Bolivia, social
emergency funds supported the construction of sewers and provision of clean water to
rural areas (Carrin, et. al., 1993).
In Malawi, changes in agricultural policy - specifically price liberalization - led to
higher food prices, which for most households caused a decrease in real incomes and a
shift from food crops to cash crops. In addition, the government removed fertilizer
subsidies, which caused a drop in agricultural productivity among smallholders. These
changes led to decreased nutritional status (Ngalande-Banda, 1993).
4.5 Environmental and infrastructure projects to improve water and sanitation
A review of findings from 100 studies about the health impact of improvements in the
quality or availability of water, or in disposal of human waste, found that improved water
supplies (quality and quantity) and sanitation can have a 26% reduction in the incidence of
diarrhoea, 28% reduction in the incidence of roundworm, 76% reduction in cases of guinea
worm, and 73% reduction in cases of schistosomiasis (Esry, et. al., 1991). One study estimated
that “well-designed projects combining water supply, excreta disposal, and hygiene education
may achieve reductions of 35 to 50% in diarrhoeal morbidity” (Martines, et. al, 1993)
27
Comparing the two strategies, a recent study demonstrated that improvements in
sanitation had a greater impact on reduction in diarrhoeal prevalence than improvements in water
but that providing sufficient amounts of water for good hygiene may be just as or more important
than providing good quality water (WHO, 1997b, p. 141). Good management and effective
strategies are critical in ensuring that such improvements actually reach the poor.5
Furthermore, several projects have demonstrated that installation of latrines and boreholes must
be combined with education to promote the use of these facilities and relevant behaviors. In
addition, such efforts are most effective when they are part of large-scale efforts to improve
overall socioeconomic and environmental conditions of communities. For example:
The township development program in Myanmar began over 20 years ago to construct
sanitary latrines for each household, provide safer supply for tube wells for every village,
ensure immunization and deliveries by trained health personnel, and prevent and control
leprosy and plague. Sinking of tube wells increased irrigation capabilities as well, which
resulted in increased agricultural productivity. Replacement of firewood by waste
materials for domestic energy production improved the environment. (WHO, 1997a,
Background Materials)
The city of Jakarta, Indonesia undertook a poverty alleviation effort nearly 30 years ago
that focused on upgrading of kampongs (shanty towns). Initially it replaced temporary
dwellings and made improvements in roads, drainage, and water supply. As the program
grew, it took on solid waste disposal, construction of sanitary facilities, promotion of
horticulture, health training, and vocational and non-formal education.
WHO’s Healthy Cities Programme (and related Healthy Villages, Islands, and
Markets) which operates in thousands of communities around the world seeks to include
all development sectors and agencies at the community level, including local residents,
in the planning and implementation of activities that improve the physical, social and
economic environment. (See Tsouros, 1992, and WHO, 1996c, for a review of strategies
and structures for integrated approaches to local health and development.)
Other infrastructure investments, especially in rural areas, may also have important health
benefits. For example, rural electrification in South Africa has been one of several poverty
alleviation projects of the new Government. In addition, it was expected to have important
5 The Water Supply and Sanitation Collaborative Council, with representation from several UN
agencies, serves as a resource to developing countries and external support agencies to accelerate
provision of sustainable water supplies, and sanitation and waste management services, particularly to
the poor.
28
health benefits: reduction of air pollution, of the number of house fires and bums to children,
and cases of paraffin poisoning in homes that rely on this fuel. Research demonstrated that the
health system alone would save more than US$200 million by avoiding the cost of treating
respiratory illnesses, bums and poisoning (WHO, 1996a and von Schirnding, 1997) In many
other countries, intersectoral action on a broad array of health-and-environment issues (not
limited to water and sanitation) has been inspired by a UNDP-WHO initiative that helps
governments integrate such considerations into national development plans. These efforts are
reflected in the plans of Jordan, Guatemala, Guinea-Bissau, Iran, Nepal and the Phillippines.
29
5.
INITIATING AND MAINTAINING INTERSECTORAL ACTION
Assuming that health policy-makers want to stimulate intersectoral actions and that they
have identified the sectors they want to target, many challenges lie ahead of those who want to
start intersectoral projects. "Often few or no mechanisms are available to enable health policy
makers to have a significant role in the national development policy-making process ... [and as
a result], problems that increasingly require multi-sectoral approaches do not receive adequate
attention and are thus compounded.” (Rodriguez-Garcia, et. al., 1994) The premise of this paper
has been that the marshalling of information, and analysis of data on the health impacts of other
sectors, will go a long way toward empowering health ministers to become involved in the design
and implementation of development strategies and policies in other sectors. However, data alone
is rarely enough to make a difference.
5.1 Prerequisites for intersectoral action
The ability of the health policy-makers to influence development policies of other sectors
for health requires at least five critical prerequisites: 1) instilling the belief among health
professionals in both the public and private sectors that a key strategy for improving the health
of the poor is to work with other sectors on poverty reduction; 2) pressure from NGOs, private
businesses, local governments, and international agencies to make health considerations more
central to development policies aimed at the poor; 3) recognition among the general public that
better health is an integral part of community development; 4) commitment to ensuring that the
poor are involved in intersectoral decision-making and implementation; and 5) having or
developing the technical capacity to advise other sectors about modifications to their activities
that would improve health and reduce poverty more effectively. The last is particularly important
since ’’setting priorities on paper, when the capacity to implement them is weak, is clearly a futile
planning exercise.” (Bobadilla, 1996) If the analytic capacity does not exist with a Ministry of
Health, linkages with research centers can help fill the gap. Responsibility for acting on their
findings and bringing stakeholders together to set priorities, however, remains with the
government.
5.2 When to initiate intersectoral action for health ?
In considering when to restructure or reorient health policies to incorporate intersectoral
action and poverty reduction, timing can be critical. In some countries that have recently
undergone profound political change or civil war, the founding of a new government or the
30
aftermath of civil war may create new opportunities to take a new approach to health planning
and policy making that strongly incorporates poverty reduction and intersectoral action.
Mozambique is an example of a country that used its post-war reconstruction efforts as a starting
point for reexamining national health policy (Noormahomed and Segall, 1994). Most countries,
however, will have to take a more incremental approach to changing the way they look at health
policy’s contribution to poverty reduction. A new overall development plan (not just a health
plan) may present a good opportunity to re-examine how the health system can contribute to a
country's overall development goals, and in turn, how the goals and projects proposed for overall
development will impact or contribute to health. The adoption of policies at international
organizations and meetings, including WHO's recent global health policy, may provide another
impetus for reexamination of health priorities within a country.
5.3 How to initiate and plan intersectoral action
Part 4 of this paper suggests an approach for assessing opportunities to improve health
through poverty reduction efforts, and for selecting priorities among potential projects with all
relevant stakeholders. Once priorities are established through that process, the development of
strategy and implementation plans requires that structures and processes be established for
creating long-term partnerships. As in considering the problems and setting the priorities, all
relevant stakeholders must be involved in such partnerships to define their respective roles and
responsibilities. Clear and measurable objectives must be set, implementation plans developed,
budgets and staff allocated, and technical assistance obtained if necessary to put plans into action.
Monitoring, evaluation and feedback are important to refine approaches and overcome new
obstacles that arise. Lessons from intersectoral experience for each of these steps are described
elsewhere (WHO, 1997d).
5.4 Implementing and maintaining intersectoral action
Maintaining the momentum of intersectoral action requires above all political
commitment and leadership. Often, a single highly visible and powerful leader's commitment
has been the decisive factor in intersectoral action's success. But when specific intersectoral
activities are large in scope, or have long-term time frames for implementation, it is better to set
in motion a mutually reinforcing approach that uses more broad-based bottom-up and top-down
planning and decision-making structures (WHO, 1997d). The result of a bottom-up process that
identifies intersectoral threats and opportunities at the local level might be used to develop a
national strategy or action plan, while a top-down approach might set forth the national strategy
that provides the impetus and structure for regional or local intersectoral activities. In Guinea-
31
> f.
0515;
Bissau, for example, efforts by WHO to strengthen district-level management led to elaboration
of a national health plan based on regional priorities (ICO, 1996).
The advantage of carrying out both approaches simultaneously is that national strategies
will reflect greater input and involvement from people at the local level, while local actions will
can be coordinated to achieve greater overall effect than if they were conducted in a vacuum.
Such approaches also build broader public support, political constituencies, and bases of
experience that each level can use to help each other in carrying out agreed upon actions and
priorities.
32
References
Anand, S., and K. Hanson, 1997. "Disability-adjusted life years: a critical review," Journal ofHealth Economics,
16(6): 685-702.
Anand, S., and L. Chen, 1996. Health Implications of Economic Policies: A Framework for Analysis, UN
Development Programme, Office of Development Studies, Discussion Paper Series, January.
*
Baah, A., "Health Economics: Identification of Needs in Health Economics in Developing Countries," WHO Task
Force on Health Economics, WHO-TFHE-95.3.
Bahaa El-Din, H.K., 1998, "Linking Health and Education," Education for All 2000, UNESCO, No.30, JanuaryMarch.
Bobadilla, J.L., 1996. “Priority Setting and Cost-Effectiveness”, in Health Policy and Systems Development: An
Agenda for Research, Janovsky, K. (ed.), WHO
Boer, L. and J. Rooimans, (eds.) 1994. "The World Bank and Poverty Reduction",Contributions to a seminar, The
Hague, November 1993, Netherlands Ministry of Foreign Affairs.
Bourne, D., 1994. Analysis ofmortality data for 1990. Unpublished report prepared for the Health Expenditure
Review, University of Cape Town, South Africa
Carrin, G., M. Jancloes, and S.I. Ajay, 1993. “Overview and Introduction,” in Macroeconomic Environment and
Health, WHO/ICO/ME/93.1
Chandiwana, S., et.al., 1997. “The Essential Step: An Interim Assessment of Equity in Health in Zimbabwe,
Zimbabwe Ministry of Health.
Cooper Weil, D., et.al., 1990. The Impact ofDevelopment Policies on Health: A Review ofthe Literature, WHO.
Esry, S.A., et. al., 1991. “Effects of improved water supply and sanitation on [various diseases],
Bulletin of the World Health Organization, 69(5):609-621.
Evans, R., M. Barer, and T. Marmor, 1994. Why are some people healthy and others not? Aldine de Gruyter, NY.
Franke, R. and B. Chasin, 1992. "Kerala State, India: Radical Reform as Development," International Journal of
Health Services, 22( 1): 139-156.
Frenk, J., 1995. "Comprehensive Policy Analysis for Health System Reform," Health System Reform in Developing
Countries, P.Berman (ed.), Harvard School of Public Health, Boston, MA, pp. 335-361.
Gunatilleke, G.,1995. "Poverty and Health in Developing Countries," Macroeconomics, Health and Development
Series, No. 16, May, WHO/ICO/MESD.16.
Harpham, T. and C. Stephens, 1992, "Policy directions in urban health in developing countries — the slum
improvement approach," Social Science and Medicine, 35(2): 111-20, July.
ICO, 1996. "Intensified WHO Cooperation: Empirical Analysis and Lessons Learned from Technical Cooperation
with the Poorest Countries," WHO, WHO/IWC/97.2.
International Herald Tribune, 1997. “In Bangkok, Lowest of the Low Lose Jobs First,” 16 December, p.2
Jamison, D., 1993. “Disease Control Priorities in Developing Countries: An Overview”, in Jamison, Mosley, et.al.,
1993.
33
Jamison, D., W.H. Mosley, et.al. (eds.), 1993. Disease Control Priorities in Developing Countries, published for
the Word Bank, Oxford University Press.
Khairul Islam, M., 1996. “Case Study #2: The Grameen Bank, Bangladesh” in Rodriguez-Garcia, et. al., 1996 (see
below).
Kosen,S., 1996. "Estimation of national burden of disease: An Indonesian experience," Presented at the SEAMIC
technical meeting on health statistics, Yogyakarta, Indonesia, August.
Martines, Jose, M. Phillips, and R.G. Feachem, “Diarrhoeal Diseases” in Jamison, Mosley, etal. 1993.
McIntyre, D., 1997. "Input Paper on Health for the South African Poverty and Inequality Report", University of
Cape Town, Health Economics Unit, unpublished.
MkNelly, B. “Case Study #3: Freedom from Hunger,” in Rodriquez-Garcia, et. al.. 1996 (see below)
Mosley, WH, and L. Chen, 1984."An Analytical Framework for the Study of Child Survival in Developing
Countries," in Mosley and Chen (eds.), Child Survival: Strategies for Research, Supplement to v. 10 of Population
and Development Review, Population Council, NY.
Murray, C. and Lopez, A., 1996. "Assessing the burden of disease that can be attributed to specific risk factors,"
in Investing in Health Research and Development, Report ofthe Ad Hoc Committee on Health Research Relating
to Future Intervention Options, WHO, Annex 2
Ngalande-Banda, E., 1993. “Macroeconomic development and the health sector in Malawi”, in Macroeconomic
Environment and Health, WHO, 1993.
Noormahomed, A.R. and M. Segall, 1994. "The public health sector in Mozambique: a post-war strategy for
rehabilitation and sustained development," Macroeconomics, Health, and Development Series, no. 14, WHO, WHOICO-MESD.14.
Rodriguez-Garcia, R., J. Macinko, and W. Waters, 1996. "Making the Health-Development Link Through
Microenterprise Development", Background Paper for the Bellagio Conference on the Health-Microenterprise
Development Link, George Washington University Center for International Health, and the World Health
Organization.
Rodriguez-Garcia, R., Vieira, C., and Goldman, A., 1994. "A Perspective on Health and Development," in The
Health-Development Link, PAHO, WDC, pp. 1-76.
Ron, A. and G. Carrin, 1996. "The Development of National Health Insurance In Viet Nam," Technical Paper, No.
123, Macroeconomics, Health and Development Series, World Health Organization, Health Services Development
Programme, October.
Sechaba Consultants, 1994. "Poverty Mapping Exercise: 1994", Maseru.
Sen, B., 1997. "Health and poverty in the context of country development strategy: a case study on Bangladesh,"
Macroeconomics, Health and Development Series, No. 26, November.
Stephens, C., etal., 1997. "Urban equity and urban health: using existing data to understand inequalities in health
and environment in Accra, Ghana and Sao Paulo, Brazil", Environment and Urbanization, 9(1): 181-202. (April)
Tilden, R., et.al., 1994. "Selecting an Effective Strategy to Improve Health Status: Nutrition Programs, Medical
Care, Maternal Education, or Job Creation?", in Health, Economics, and Development: Working Together for
Change, Proceedings from the 7th International Congress, World Federation of Public Health Associations, Bali,
Indonesia, December.
34
Tsouros, D., ed., 1992. WHO Healthy Cities Project: A project becomes a movement. Review ofProgress 19871990. WHO Healthy Cities Project Office, Milan, SOGESS.
UN Development Program, 1997. "How Thailand eradicated serious malnutrition in a decade", in Human
Development Report, 1997, Oxford University Press, Box 2.3
»
t
Viravaidya, M and R. G. Sacks, 1997. "Health and rural-to-urban migration in Thailand," Medical Journal of
Australia, 166:152-155, February 3.
von Schirnding, Y., 1997. Intersectoral Action for Health: Addressing Health and Environment Concerns in
Sustainable Development, WHO, March (WHO-PPE-PAC-97.1)
WHO, 1998. "Health for All in the 21st Century," Executive Board Policy Statement, EB 101/8.
WHO, 1997a. Intersectoral Actionfor Health: A Cornerstonefor Health-for-All in the Twenty First Century, Report
of the International Conference (WHO/PPE/PAC 97.6), April.
WHO, 1997b. Health and Environment in Sustainable Development: Five Years After the Earth Summit, WHO.
WHO, 1997c. Monograph on Poverty and Health: Regional Issues, WHO, Southeast Asia Regional Office, New
Delhi, June. (Developed by the Marga Institute, Sri Lanka Centre for Development Studies, Colombo, Sri Lanka).
WHO, 1997d. "Intersectoral Action for Health: Addressing Health and Environment Concerns in Sustainable
Development," WHO-PPE-PCA-97.1
WHO, 1997e. "Health Services in Bangladesh:Reaching Vulnerable Groups," WHO Bangladesh Representative,
Dhaka, September, draft.
WHO, 1996a. Investing in Health Research and Development, Report of the Ad Hoc Committee on Health
Research Relating to Future Intervention Options, WHO.
WHO, 1996b. Equity in Health and Health Care: A WHO-SIDA Initiative, Paula Braveman, et. al., WHO.
WHO, 1996c. Creating Healthy Cities in the 21st Century. Background Paper for UN Conference on Human
Settlements, June 1996, Instanbul, Turkey, WHO/EOS/96.9.
WHO, 1995. Advisory Committee on Health Research, Report of DALY Review Group, WHO, 1995,
AHCR33/CPR 95.1.
WHO, 1986. Intersectoral Action for Health, The Role of Intersectoral Cooperation in National Strategies for
Health for All.
World Bank, 1996. Poverty Reduction and the World Bank: Progress and Challenges in the 1990s, World Bank.
World Bank, 1995. Viet Nam: Poverty Assessment and Strategy, Country Operations Division, East Asia and
Pacific Region.
World Bank, 1993. World Development Report 1993: Investing in Health, Oxford University Press, NY.
World Bank, 1992a. World Development Report, 1992: Development and the Environment, Oxford University
Press
World Bank, 1992b. Better Health in Africa, World Bank Africa Technical Department, August.
Wratten, E., 1995. “Conceptualizing urban poverty,” Environment and Urbanization, 7(1): 11-36 (April), Box 2.
Yach, D., 1997. “Health-for-All in the twenty-first century: A global perspective,” The National Medical Journal
ofIndia 10(2):82-89.
35
r
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
N° 28:
Poverty and health : who lives, who dies, who cares ? - Policy paper - WHO/1CO/MESD.28
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