Reaching the poorest of the poor / by Carol Aloysius

SRI LANI<A Reaching the poorest of the poor by Mrs Carol Aloysius Senior journalist with an English-language newspaper in Sri Lanka A ppuhamy, his wife Seela and their two children (aged two and four years respectively) live in a mud and wattle daub hut in a remote hamlet of north central Sri Lanka. Appuhamy, 26, the sole breadwinner in the family, is a small farmer whose uncertain income varies from 400 to 500 rupees (US $10 to $12) a month using the ancient method of "slash and bum" agriculture. This meagre income is barely suffi- cient to feed his growing family even with two square meals a day. Often these meals consist of rice or yams and sometimes a vegetable or two, and occasionally a dish of dry fish or sprats. Except on very rare occasions, the family never eats meat or fresh fish, since these two protein-rich foods are much too expensive. They drink tea plain and plenty (to make up for the lack of food), usually taken with a dash of sugar. Occasionally, when the har- vest is plentiful, Appuhamy is able to buy a packet of sweetmeats for his children. Because of their poor diet, lacking in essential vitamins and proteins, the whole family is malnourished. Seela, 21, who is expecting her third child, is also very anaemic. Occasionally she visits the maternal and child health clinic conducted regularly within five miles of her home by public health field staff. But on most days when the clinic is held, she is unable to attend it with her children as she has neither the bus fare to travel nor a change of clothes to wear. When she does manage to attend an MCH clinic, specially run to help pregnant women like herself and young children, the health workers give her iron tablets for her anaemic condition and other vitamin supplements. Sometimes she is lucky to be served a cup of kola Kende, a nutritious vegetable and rice gruel prepared by some of the health volun- teers assisting at the clinic. She also receives a free packet of T riposha - supplementary food given to all malnourished pregnant or lactating 6 mothers and underweight children before they return home. As for the two youngsters, they are examined and weighed, and their growth is recorded on a chart. Since their weight gain is below what is expected of children in their age groups, Seela is advised on suitable diets for them. The midwife warns her to eat more nutritious and adequate meals so that both she and the baby will be healthy. Despite the good advice given to her, her extreme poverty prevents her from cooking the prescribed diets. So both she and her children continue to be malnourished. Nor does the damp, ill-ventilated and overcrowded hut where they live in any way help to improve their health status. While the two young children have been safeguarded from the six common childhood diseases (polio, tetanus, whooping cough, measles, diphtheria and tuberculosis) through the universal child immunization pro- gramme, they are nevertheless prone to constant bouts of diarrhoea and respiratory infections. This again is largely due to the lack A poor family in Sri Lanka, beneficiaries of the Janasaviya (strengthening the people) Programme aimed at alleviating extreme poverty. of safe drinking water and sanitary toilets, to eating unhygienically cooked foods and to sleeping in damp sur- roundings. The children also suffer from worm infestations - there is no toilet so they have to defecate on the open compound where they play. The plight of the Appuhamy family is by no means a rare phenomenon in Sri Lanka. It is one that is shared by thousands of other very poor families in a country where over half of the rural population live below the poverty line - earning under 700 rupees a month (about US $18). A vicious circle Their extreme poverty has trapped them in a vicious circle of ill-health from which they cannot break free. It also prevents them from making the best use of the many welfare services provided by the government, such as free education and free health services. Consequently, these families have been unable to participate in the country's development or lead a full and healthy life. It is to help such families that the government recently introduced an innovative programme aimed at alleviating extreme poverty and thereby improving the overall quality of life of the poorest of the poor. The Janasaviya Programme, mean- ing "strengthening the people," was conceived by the President of Sri Lanka, Mr R. Premadasa. It is also known as the Poverty Alleviation Pro- gramme (PAP) because that is its prime goal. In Mr Premadasa's words, poverty "is synonymous with misery, bringing in its wake ignorance, disease, debilitation and defeatism." The PAP is a country\.vide response to a set of fundamental problems affecting Sri Lanka's social, political and economic order, namely, poverty, unemployment, landlessness and alienation from the land, all of which have resulted in a waste of potentially productive human resources. It will form the key strategy of the government for the next few years. Closely linked to it, and an integral component of the PAP, is another innovative programme directed at improving people's health status. This health component, developed by the Ministry of Health and Women's Affairs, is called Suva Saviya - "strengthening health." As the Presi- dent explains: "Poverty and ill-health are intricately interwoven. Poverty affects health which in turn affects the participation of the people in the social and economic development of the country." Like the PAP, the Suva Saviya programme is also a people-based one - a bottom-up process starting at hamlet level and primarily geared to the health needs of the poorest of the poor. The philosophy behind it reflects the broad definition of health proposed by WHO, namely, that health is not merely the absence of disease and infirmity, but also the physical, mental and social well-being of a person. The pro- gramme relies on the primary health care approach to achieve its goals, and the needs of the beneficiaries are obtained from a family profile main- tained by the midwives or other health workers. This approach has been selected for several reasons, all of which are compatible with the PAP. For one thing, it entails remedying the root causes of illnesses rather than the illnesses themselves, through simple, practical and cost-effective methods such as improving nutrition, providing safe drinking water, health education, school health, mother and child care including immunization, control of diarrhoea! diseases, hygiene and family planning. In other words, the emphasis A small child goes in the weighing scale for a check on its healthy growth. WORLD HEALTH. September-October 1990 WHO/ SEARO 7 is on prevention rather than cure, and on self-reliance. It is also regarded as the most effective way of making basic health services accessible to families in an affordable and acceptable way, while ensuring their fullest cooperation and participation. While the overall objective of the Suva Saviya programme is to raise the health status of the beneficiaries in general, it puts special emphasis on mothers and children - regarded as the two most vulnerable sectors of this target population. For although Sri Lanka's infant and child mortality rates are among the lowest in South-East Asia, there still exist significant differentials between geographic, social and economic groups. Malnutrition and under- nutrition among young children is widely prevalent in certain areas, and leads to chronic stunting. Anaemia and poor maternal nutrition is common among mothers in the low income groups, resulting in low birth weight babies. Post-partum haemorrhage is . one of the commonest causes of maternal mortality - and its victims are already anaemic mothers. As in other countries of the Region, a large number of these illnesses and deaths could be prevented, if suitable strategies could be developed and carried out. The country has a wide 8 network of health institutions ranging from big teaching hospitals to central dispensaries, maternity homes and clinics but, as we have seen, poverty often prevents people from visiting them regularly. Even the home-visiting services provided by the midwife and the public health inspector often meet with poor compliance on the part of some mothers. The Ministry, which is responsible for planning, organizing, coordinating and evaluating MCH programmes, trains and orientates field health workers to pay special attention to the health care of mothers and children. It urges public health nurses, public health inspectors, midwives and pre- pupil midwives to ensure that everyone receives the fullest benefits from the wide spectrum of health services pro- vided free. These programmes for mothers and children are largely funded by leading international agencies such as WHO, UNICEF and UNFPA (the UN Population Fund). Services under the Suva Saviya programme will include· ante-natal, natal and post-natal care, nutrition programmes for malnourished ·mothers, immunization for children against common chikihoqd diseases, growth monitoring of the young child, promotion of breast-feeding, and appropriate weaning practices. Family Keeping the records up-to-date. The new approach to health care in Sri Lanka is already winning a positive response. planning is also emphasised, with the accent on birth spacing. Attention will also be paid to child mental health, control of diarrhoea! diseases and acute respiratory infections, and school health. The public health midwife is the first formal contact point with ordinary people in the field of primary health care. On her efficiency largely rests the succe~s of the Suva Saviya programme. Close collaboration between the Ministry and both WHO and UNICEF, from the planning stage onwards, has proved specially valuable. WHO is to carry out a project to evaluate the impact of the two programmes - the PAP and Suva Saviya - on the lives of the people who benefit from them. Although it is too early yet to say what impact the Suva Saviya concept has had, field visits made by Ministry personnel show that there is indeed a positive response to the new approach. In the fullness of time it should revolutionise the health status of all mothers and children in the poorest of poor communities in Sri Lanka and thus offer them a chance of a better life. • WORLD HEALTH, September-October 1990