Reaching the poor
Authors: Tessa Richards
Journal: BMJ (2005)

Globally around 1.2 billion people live on less than $1 a day. The erosive impact of poverty on their health and the link between ill health and poverty is well known.1 But most interventions aimed at alleviating poverty and improving health in poor countries help the better off more than the most disadvantaged.2 Such inequity of impact is often conveniently masked by expressing outcomes of evaluations as population averages, a flaw inherent even in the three health related millennium development goals. Now a report from the World Bank looks at the evidence and suggests how to reach the poor more effectively.3

The data in the report, from 78 programmes on health, nutrition, and population conducted in 56 poor and medium income countries between 1990 and 2001, are sobering. Under-5 mortality was more than twice as high among the poorest fifth of the population than the richest fifth (see bmj.com). The richest fifth was also much more adept, by an order of two thirds, at accessing basic health services.

Concern about inequalities in the coverage of both public and private health and education programmes has grown a lot faster than knowledge of what to do about this uneven coverage. Under the rubric of “what works, what doesn't, and why” the report seeks to plug this knowledge gap. It does this with reference to some of the 19 new case studies commissioned and supported by its Reaching the Poor programme, which was set up in 2001 in collaboration with the Gates Foundation and the Dutch and Swedish governments.4

Most of the interventions described have succeeded in bringing health benefit to 50% or more of the poorest fifth of the populations they covered. This contrasts with the 10-20% achieved by most health intervention programmes and challenges entrenched views about the inevitability of the inverse care law.

The projects have used a wide variety of strategies to reach the poor and the report provides useful detail of the new methodologies used to design, monitor, and evaluate them. In Cambodia the ministry of health contracted with non-governmental organisations to provide rural primary health services in trial areas. Over four years, this led to a doubling of access to services by the poorest fifth of the population.

Distributing bed nets treated with insecticide through existing campaigns for measles immunisation worked in Ghana and Zambia; social marketing of treated bed nets succeeded in Tanzania. Mexico's “Progresa Oportunidades” programme has reached the poorest 40% of the population by paying poor families to attend health clinics and send their children to school. In Gujerat in India the SEWA (Self Employed Women Association) programme has empowered local women, most of whom are poor themselves, to educate people how to use local mobile services for reproductive health.5

Collectively these studies go a long way to answering the questions on what works and what doesn't, but the “why” remains elusive. The diverse approaches pursued in equally diverse settings led the authors to conclude that searching for universally successful strategies is a misguided enterprise. They also acknowledged that growing inequalities in health depend as much or more on a myriad of social, political, economic, and environmental factors than on the availability or actions of health services.

Nevertheless, the report contains some clear messages for health policy makers: firstly, to recognise that many of their programmes exacerbate rather than reduce health inequity and that it is possible to do better; secondly, not to simply copy strategies that have worked elsewhere, but to learn from them and adapt them to different contexts. Around $380bn is spent annually on providing health services in low and middle income countries.3 The obligation to ensure that this money is spent on interventions that bring maximum benefit to those most in need is overwhelming.