Author: Adam Wagstaff, Lead Economist, Development Research Group and Health, Nutrition and Population Network, and Professor of Economics, University of Sussex
Poverty and ill health are intertwined. Poor countries tend to have worse health outcomes than better-off countries. In high-income countries, only six children out of every 1000 born die before their fifth birthday. In the developing world, the figure is 88. In the world's poorest countries, the figure is 120. Within countries, too, poor people have worse health than better-off people.
In Indonesia, under-five mortality is nearly four times higher in the poorest fifth of the population than in the richest fifth. These gaps show signs of widening. Between 1970 and 2000, under-five mortality fell by over 71% in high-income countries. In low-income countries, the reduction was only 40%. In Bolivia, during the 1990s under-five mortality fell by 34% amongst the richest quintile but by only 8% amongst the poorest quintile. In Vietnam, poor children saw no appreciable improvement in their survival prospects during the late 1980s and early 1990s.
Poverty leads to ill health which leads to poverty…
The association between poverty and ill health reflects causality running in both directions. An illness in a household, or excessively high fertility, can have a substantial impact on household income. As an Egyptian woman put it in Voices of the Poor, "We face a calamity when my husband gets ill. Our life comes to a halt until he recovers and goes back to work." Low levels of health keep countries-and whole continents-poor. Health and demographic variables have been estimated to account for as much as half of the difference in growth rates between Africa and the rest of the world over the period 1965-1990. High fertility itself has major repercussions for poverty. If the average country had reduced its birth rate by five per thousand persons throughout the 1980s, poverty incidence would-according to one set of estimates-have fallen from 18.9% to 12.6% between 1990 and 1995. Furthermore, ill health is often associated with substantial health care costs. Voices of the Poor recorded the case of a 26 year-old man in Lao Cai, Vietnam, who, as a result of the large health care costs necessitated by his daughter's severe illness, moved from being the richest man in his community to one of the poorest. Health expenses are estimated to have pushed around 3 million Vietnamese into poverty in 1993 and somewhat fewer in 1998.
But poverty and low income are also a cause of ill health. Poor countries-and poor people within countries-suffer from a multiplicity of deprivations that translate into high levels of ill health. They tend, for a start, to have less money than the better off. This limits the amount of medical care, food, clothing and shelter they can afford. But their deprivation goes further. The poor tend to be uneducated and, as is well known, education has a substantial influence on health outcomes through its effect on the utilization of effective interventions. The poor often face a higher price of health services at the point of use, being less likely to be covered by a private or public health insurance schemes. Fee-waivers and health cards in some countries offset this tendency, but in many they are poorly targeted. The poor tend to live in underserved areas and incur higher time costs in seeking health care. The facilities serving them are often less well organized than those serving the better off, with inconvenient opening hours and providers who are insensitive to their needs. The quality of care in the facilities serving the poor is also often poor, with providers being unwilling to serve in the areas the poor live in and drugs and other inputs being in even shorter supply than in facilities serving better-off areas. And, of course, the poor tend to have worse access to drinking water and improved sanitation.
Poor people and poor countries are thus caught in a vicious circle-their poverty breeds ill health; and this, in turn, conspires to keep them poor. The poverty-health linkage thus matters twice over. It matters because the poor are disadvantaged in terms of a key dimension of well-being. As Nobel laureate Amartya Sen has put it: "health is among the most important conditions of human life and a critically significant constituent of human capabilities which we have reason to value". But the linkage matters too because death and illness act as a brake on economic growth, and contribute to income poverty. It thereby limits what countries and people can achieve on other dimensions of well-being.
Breaking out of the vicious circle
A two-pronged approach is required: to reduce the likelihood of people getting sick and dying; and to reduce the impact on households' living standards when their members do fall sick or die. The first requires reducing the barriers that the poor face when using health services. Care can be made affordable by expanding insurance coverage to the poor, as in Colombia's social health insurance program, or through carefully targeted fee reductions, as in Indonesia's health card scheme. Accessibility can be improved through outreach, road improvement and rehabilitation programs, and contracting with private providers and NGOs. The human and material resources in facilities serving the poor can be increased through a variety of mechanisms. Thailand and Malaysia, for example, succeeded in getting doctors to rural areas, as has Uganda recently.
Often action is required on several fronts. For example, reducing the price of health care at the point of use will have relatively little impact on use of services if facilities are inaccessible and offer poor quality care. Expanding services to underserved areas is unlikely to make much of a difference unless the providers are properly motivated and resourced. Providing access to safe drinking water may yield relatively small health payoffs to the poor unless accompanied by a program to modify hygiene (hand-washing, etc.).
Reducing the impact of ill health on household income requires a mixture of policies: reducing the price of health services, but also reducing the income losses associated with ill health. Recent evidence from Indonesia suggests that with the advent of subsidized care in that country income losses from ill health are more important than health care costs in reducing household living standards.
Training and commitment to equity in the health sector
Governments that are committed to equity achieve more equitable outcomes in the health sector. In countries such as Costa Rica, Malaysia and Sri Lanka, and in the Indian state of Kerala, the incidence of health sector subsidies across income groups is relatively even. In some cases, it is even somewhat pro-poor. This contrasts with other countries and other Indian states, where subsidies accrue disproportionately to the better off-this despite the greater medical needs of the poor. Success in getting public spending to the poorest groups-those whose medical needs are greatest-reflects in part a commitment to equity on the part of policymakers. This seems more likely to come about if communities are involved in policy formulation. It is for this reason that community consultation is intended to be part of parcel of the process of producing PRSPs. A commitment to equity on the part of the people responsible for implementing policy-civil servants and providers-can be strengthened by having an equity-focused M&E strategy, especially if results are made public and are fed into performance assessment.
But commitment to equity and an equity focus in policymaking and policy implementation can be enhanced through training. Rarely does equity feature in medical school curricula or in-service training programs. The World Bank Institute's training program on Poverty, Equity and Health is thus a welcome attempt to help countries inject some much needed thinking on these issues into their policy design and implementation. It is the latest in a series of initiatives in this area, the first being a training event accompanying the launch of the World Bank's A Sourcebook for Poverty Reduction Strategies.
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