A strategy against poverty

6 World Health • 47th Year, No. 6, November-December 1994 A strategy against poverty W. A. Hassouna The aim should be to put "reasonable quality of core" at on affordable cost within the reach of the poor, rather than offering low quality of core at cheaper prices. Everybody's treatment-seeking behaviour is influenced by several factors which include their level of health awareness and their perception of disease, sickness and health as well as their accessibility to health services. Access to health services in tum is affected by several factors, such as: • the physical distance or travel time between the patient's home and the health providers; • the social acceptability of the services to the patient, which includes attitudes, behaviour and gender of the service providers; • the patient's perception of the appropriateness or effectiveness of services in relation to their health condition- namely, quality of care; • the patient's ability to pay for the required services- namely, the cost of care. Among these factors, the cost of health services seems to be the most crucial variable affecting the patient's decision to use or not use the service. This includes both the direct cost which the person pays to the service provider, and indirect costs which the patient is obliged to bear, such as travel time and cost of transport, deductions from salaries or wages, or payment to a baby-sitter for tending the children during the patient's absence from home. Queuing at a health centre in Lesotho. Access to health care is a key escape route from poverty. It is evident that people tend to use less costly services, i.e. those within their economic means, especially when they feel their needs are being satisfied. On the other hand, some people may be willing to go beyond their economic means to pay for health services when they perceive this is necessary to avoid intolerable pain, severe disability or threatening death. They may borrow money or sell some of their assets or even take illegal measures to pay for costly health services. Others may delay their use of health services or may not use them at all because they are beyond their economic means, while rationalizing their behaviour in various ways. Or they may resort to consulting neighbours, friends, family members or quacks to avoid paying the high cost of health services. It is commonplace for people to tum to pharmacists in order to avoid paying physicians' fees. Promoting access In these circumstances, it is obvious that promoting free or low-cost access to health services is one of the crucial strategies which could enable the poor to use the resulting savings to satisfy other vital needs like food, clothing, heating and so on. Poor people spend a sizeable percentage of their disposable income on health services; the proportion varies between 15% and 20% and is usually less than half what they spend on food consumption. So increasing people's accessibil- ity to health services -within their ability to pay- could positively change their treatment-seeking behaviour. They would resort earlier to health services and hence benefit from early detection, diagnosis and treatment. This would subsequently enable them to save expenditure on chronic or complicated cases. It is worth noting here that women and children are more affected by poor accessibility to health services, and this situation is more common in the countryside than in the cities. In most developing and some developed countries, governments have been the major providers of preventive and curative health care. These services used to be accessible to the poor since they were provided without charge. But the unpreceden- World Health • 47th Year, No. 6, November December 1994 ted escalation of the cost of health services in the last ten years and the adoption of economic reforms which usually resulted in sizeable reduc- tions of allocations for health services have greatly reduced the access of the poor to government health services. Such reforms have affected curative more than preventive care since many governments provide the latter free or at minimal cost. Immunization for a child in Jamaica; it costs nothing- and may save a life! NGOs and the private sector As a result of the reduced role of the government as health provider, the private sector and nongovernmental organizations (NGOs) have started to contribute a bigger share to the health services. The fact that the private sector is profit-oriented tends to put such services far beyond the poor people 's ability to pay. This leaves the NGOs with an increased responsibility for providing health services, mainly to the poor. The ways in which NGOs can increase access to health services, especially for the poor, include: • bringing services- particularly primary health care - closer to the people; • charging very low fees for services; • providing a simple mechanism for group health insurance with reasonably low overheads. In some countries, NGOs- which frequently have religious affiliations and are socially acceptable - have A nurse in India checks on a child's nutritional status by measuring the circumference of the arm. Cost should not deter poor people from offending primary health core services. proved to be very effective in increasing the accessibility of health services to the poor. Several ways have been adopted in various countries to increase access to health services, all of which are aimed at reducing the patient's economic burden. Unfortunately, most of the approaches such as health insurance and cost-sharing are geared to helping middle-income groups rather than the poor who cannot afford to pay insurance premiums or even reduced fees, and in many cases will not have the cash to pay for health services when they are seriously sick. It seems clear that what is needed is a system that ensures for the poor a reasonable access to health services with a minimal economic burden. This could be done by including specific health benefits within a com- pulsory social insurance system or making available interest-free loans from group savings to be used in case of sickness. Certainly, increasing access to health services as a strategy for poverty alleviation should be dealt with in a comprehensive manner that takes into account physical, social, cultural and economic factors. The ultimate aim should be to put "reasonable quality of care" at an affordable cost within the reach of the poor, rather than offering low quality of care at cheaper prices. • Professor w. A Hassouna is Director General of the Community Development Programme, Social Fund for Development, I Wadi El Nil Street, Mohandesine, Cairo, Egypt. Basic minimum needs in the Eastern Mediterranean The Eastern Mediterranean Region of W HO is promoting the basic min imum needs (BMN ) approach in the Reg ion as on innova ti ve mea ns of ensunng equity in health care, a better quality of life and new hope for disadvantaged commun tttes. This approach is based on self- relian ce and community participation , w ith WHO act~ng as a catalyst, essentially leavt ng it to each communi ty to rectify potentially unhealthy situations. Imposing "correct " answers to problems or simply supplyi ng a drainage system, for example, may have on ly a short-term beneficial effect. Unless villagers are themselves involved in working out solutions and putting them in to practice, they neither believe in nor respect such outside aid . Th ey have no incentive to maintain or even to use the facilities . Under the BMN approach, a vi llage community may first be invited to part ic ipate. Th en W HO staff may prepare a questi onnaire asking about fa mi ly size, the sou rces of drinking-water and so forth. A set of general goa ls may be suggested: perhaps tha t every person shou ld be no more than half-hour 's wa lk from drinkable water, or that children 's growth should be monitored to ensure their adequate nutrition. The vil lage then decides on which priority it wishes to spend its money and time. The atm ts to improve many aspects of village life a little , rather than transfo rming any g iven sector com pletely. W here necessary, W HO offers five-year, interest- free loans to vi llage cooperatives fo r schemes w hich may include starting a vi llage health cen tre , promoting cash crops, or even encouraging bee-keeping. 7