International
Good intentions are not enough: Too few health programs reach poor; Better results possible - World Bank Report
By Finfacts Team
Dec 7, 2005, 14:00

A new World Bank report today warns both developing countries and the international development community to check for gaps between intentions and verifiable results in helping poor people battle illness and disease. Health programs designed to reach poor people often end up instead helping the better-off, the study says. However, it adds that this situation can be avoided, and based on a number of successful national case studies, offers governments key policy steps to make sure that disadvantaged groups get the crucial health care services they urgently need.

According to the new study — Reaching The Poor: What Works, What Doesn't, and Why — health, nutrition, and population programs often fail to reach those poor people that need them the most, contrary to what health policy makers in developing countries and international assistance agencies intend and often assume is happening.

The Reaching the Poor Program constitutes an effort to go beyond the diagnoses of coverage inequalities like those shown in figures 1 and 2, in order to find ways of reducing those inequalities by raising coverage among the poor. By assessing the record of current and recent health, nutrition, population initiatives, it hopes to alert sponsors of poorly-performing programs to a problem of which they are likely to be unaware, and to draw their attention to approaches that have proven more effective and are thus potentially worthy of adoption.

Drawing on experience from African, Asian, and Latin American countries, the report documents that both public and private services—including services undertaken specifically to help the disadvantaged— usually end up reaching people in better-off groups more frequently. For example, the report finds that in almost all of the more than 20 countries surveyed, the richest 20% of the population received more, or as much as, of the government's subsidized maternal and child healthcare services as the poorest 20%.

“This report shows there's a huge difference between just thinking you're reaching the poor with beneficial healthcare services, and actually succeeding,” says Davidson Gwatkin, co-author of the new report, and World Bank Adviser with its Health, Nutrition, and Population Department. “But success is possible. We see plenty of encouraging examples of where governments and NGOs were able to try out and implement different approaches that helped to make a difference in the lives of poor people.”

Based on the findings in the new report, a follow-up action plan has been agreed to identify and encourage those strategies that give disadvantaged groups the health, nutrition, and population services that they need for healthy, productive lives.

Examples of where services do reach poor people

By assessing the track record of both current and recent health initiatives, the study authors and sponsors – the Gates Foundation and Dutch and Swedish Governments as well as the World Bank—hope to alert governments and health workers to poorly-performing programs, and more importantly, to amplify approaches that have proven much more effective. So where have the programs reached the people they were intended to help? Among the examples identified by the Reaching the Poor study authors are:

• Mexico's “Progresa/Oportunidades” program, which pays poor families for clinic and school attendance. The Program serves over 20 million people, and its benefits provide more than 20% of the income of its customers. Almost 60% of the people reached belong to the poorest 20% of Mexico's population; 80% of beneficiaries are in the Mexican population's poorest 40%.
• Colombia's use of a refined individual targeting technique to provide subsidized health insurance to the disadvantaged. This raised insurance coverage in the poorest quintile of the population from well under 10% in the early 1990s to nearly 50% four years later. 35% of the total program subsidy went to the poorest 20% of the population; 65% to the poorest 40%.
• Cambodia's experiment in contracting with non-governmental organizations to operate governmental rural primary health services under contracts calling for attainment of specified coverage levels among the poor. During a four-year experiment, the coverage among the poorest 20% of the population of eight basic services rose from an average of below 15% to over 40% in two experimental districts with a total population of around 200,000. This increase was nearly two and one-half times as large as that experienced in two control districts that continued to receive standard government services.
• Distribution of insecticide-treated bed nets through measles immunization campaigns in Ghana and Zambia. In Ghana, the Red Cross and the Government Health Service raised, from 3% to nearly 60%, the rate of treated bed net use among children in the poorest 20% of people in a northern district with a population of around 90,000. A similar program in Zambia produced comparable results: an increase in treated bed net coverage from 18 to 82% in the poorest 20% of the population in five rural districts with a total population of 450,000.
• Marketing of insecticide-treated bed nets in Tanzania. In two southern districts, with a total population of about 60,000, the Ifakara Health Research and Development Centre developed and implemented a social marketing program that raised the ownership of bed nets in the poorest 20% of households from 20 to 73%. As in Ghana and Zambia, the increase in bed net use/ownership was higher among the poor than among the better-off.

“Over the decades, global health programs have attempted to reduce health inequities by targeting the poor, but most evaluations have shown that even programs consciously targeting the poor, end up providing more benefits for the rich,” says William H. Foege, Senior Fellow,

Global Health Program, at the Bill & Melinda Gates Foundation. “Reality trumps intent. The global health world owes a debt of gratitude to the authors of this new World Bank report for finally providing some encouraging news.”

Building on the Successes

The report acknowledges that while these successful examples are encouraging, the wide variety of approaches used to make them work suggest the absence of a single, simple, universal solution. Rather, the variety of approaches reflects the fact that poverty and inequality result from combinations of persistent factors that can differ widely from country to country, and from region to region.

As a result, the report avoids identifying 'magic wand' approaches that can guarantee success wherever applied. Instead, it advocates a process of adaptation, recommending that country policy makers seek to fit to their own settings those strategies proven successful elsewhere that seem most relevant to their own situation. Critical in this process, note the authors, will be a solid understanding of why the poor were not getting services. Moving past thinking that governments, donors, and development agencies always know the answers, and working hard to understand the ingredients of inequalities are the obvious next steps to creating policies that fit the needs of the poor.

“These new findings certainly mark a promising beginning that provides important grounds for hope,” says Abdo S. Yazbeck, co-author of 'Reaching The Poor,' and a Lead Health Economist, for the World Bank Institute. “By following the evidence of what actually works in getting healthcare programs to poor people who need them the most, and not just accepting things at face value, our findings show that vigilance and hard work can make a difference.”

Click here for report.