17_WDR_Ch08.qxd 8/14/03 9:44 AM Page 133 Health and nutrition services Poor people in most countries have the worst • Getting highly transaction-intensive and health outcomes. They are pushed further discretionary individual-oriented clini- into poverty due to ill health. And they are cal services to poor people is most chal- chapter often excluded from support networks that lenging. To influence quality, poor clients enhance the social and economic benefits of should have greater power—through good health. Unlike education, health and third-party payments, information, and nutrition outcomes of poor people are pro- greater oversight of health workers and 8 duced by households—with contributions facilities. Organized citizens can exert from many services. And health and nutri- this power by contributing financial tion services contribute to other aspects of resources and co-producing and moni- human welfare, such as protecting people toring the services. But insurance market from catastrophic health spending. They failures, asymmetries of knowledge, and should thus be judged by the way they con- conflicts of interest mean that govern- tribute to the poor’s health outcomes, to pro- ments need to invest in purchasing key tecting citizens from impoverishing health services to protect poor households and expenditures, and to helping the poor break foster a pro-poor professional ethos. out of their social exclusion. • Population-oriented outreach services— Throughout history, poor people have standardized services that can include vec- often paid health providers directly. But this tor control, immunization, or vitamin A short route from client to provider is supplementation—are easier for policy- blunted by asymmetries of information and makers to monitor. Even governments conflicts of interest. Another problem: poor with limited capacity can provide these people lack the money for market transac- services—or write contracts with public tions. A variety of market failures—disease- or private entities to provide them. Build- related externalities and fragmented insur- ing coalitions to strengthen poor people’s ance markets—and concerns for equity collective voice is essential to ensure ade- justify public intervention in financing quate public resources for those services. health and nutrition services. But govern- • For community and family-oriented ments find it difficult to monitor the per- services that support self-care—such as formance of health workers, especially information and social support for pro- those delivering highly discretionary ser- moting breastfeeding or safe sex—com- vices, such as clinical care. And since insur- munity and civil society organizations ance-market failures affect everybody, the and commercial networks are often well non-poor often capture public financing of placed to provide services close to poor health care. households. Governments can establish Health services are failing poor people partnerships and provide information not because of lack of knowledge for pre- and targeted subsidies. venting and treating illnesses but because health systems are trapped in a web of failed Policymakers need to be accountable for relationships of accountability. To break out health outcomes—which means greater invest- of this trap, service delivery arrangements ment in monitoring and evaluation mecha- can be tailored for three classes of services: nisms that capture disparities in health.359 133 (c) The International Bank for Reconstruction and Development / The World Bank 17_WDR_Ch08.qxd 8/14/03 9:45 AM Page 134 134 WORLD DEVELOPMENT REPORT 2004 The health of poor people and poor.363 The poor also often suffer from BOX 8.1 Ethnicity Health outcomes improved in the second higher rates of noncommunicable diseases and health half of the 20th century, a trend likely to such as depression and cardiovascular dis- eases in North America or alcohol-related In the United States,according to continue in many countries. But hopes for 2000 data,indigenous Americans an ever-improving trend are fading as ailments in the Russian Federation. Malnu- and Alaskan Natives have a life progress slowed down in the 1990s. At the trition is a double burden: poorest groups expectancy five years lower than current pace most regions of the developing have both high rates of malnutrition and that of the general population.Aus- diabetes and obesity.364 tralia’s Aboriginal Health Service world will not reach the Millennium Devel- notes that in 1996 life expectancy opment Goals for health by 2015 (figure Improving health outcomes for the poor was 20–25 years lower for abori- 8.1). Infant mortality rates are increasing in is a complex task. In addition to income, gines than for their non-aboriginal Central Asia. Under-five mortality is on the other household factors influence health out- counterparts.In Chocó,Colombia, comes: age, social status, religion, residence where 90 percent of the popula- rise in 22 countries in Sub-Saharan Africa. tion is of African descent,the male Stunting is rising in many African countries (chapter 1), ethnic background (box 8.1), and infant mortality rate is more than and remains high in South Asia. In 1995, gender—particularly in South Asia. Girls in 90 per 1,000 live births,while the 500,000 women died worldwide as a result India are 30 to 50 percent more likely to die national average is 25 per 1,000.In 365 Guatemala people born in the cap- of complications associated with pregnancy, between the age of one and five than boys. ital have a life expectancy 10 years mostly in developing countries. The AIDS Maternal mortality depends mainly on health higher than those born in the epidemic is expanding in Africa, India, services while nutrition and under-five mor- department of Totonicapán,where China, and Russia, along with a resurgence tality depend on many other services, such as more than 96 percent of the popu- 360 lation is indigenous.The ratio of of tuberculosis. Adult mortality rates have education, water, food security, communica- stunting prevalence in indigenous worsened in the Russian Federation and tion, electrification, and transportation. The versus nonindigenous populations some of its neighbors. AIDS epidemic has particularly challenged is more than double in Colombia, policymakers and providers to look at links Peru,and Ecuador.The 1996 South The outcomes are consistently worse African Census reveals that despite among the disadvantaged. In low-and mid- with other sectors and focus more on behav- the government’s systematic dle-income countries, under-five mortality ior and societal values. efforts,the infant mortality rate was rates are 2.3 times higher among the poorest 5.5 times greater among the black Health services can work population than among the white fifth of the population than among the rich- population,a significantly larger est fifth. Stunting rates are 3.4 times higher for poor people 361 disparity than would be predicted (figure 8.2). The rich fare well in absolute Experience from Brazil, Chile, Costa Rica based on income differences. terms. In Pelotas, Brazil, infant mortality for and Cuba (spotlight), Iran (box 8.2), Nepal, Source: Torres Parodi (2003). the richest 7 percent of the population in Matlab (Bangladesh), Tanzania, and several 1993 was comparable to the average for the West African countries (spotlight) shows 362 Netherlands in 1998. that health services, if delivered well, can Communicable diseases, malnutrition, improve outcomes for even the poorest and reproductive ailments account for most groups. A health program in the Gadchiroli of the mortality gap between high- and district in India reduced neonatal mortality low-income countries and between the rich rates by 62 percent. Midwifery services and community hospitals are linked to dramatic Figure 8.1 Reaching the MDGs in health: accelerate progress reductions in neonatal and maternal mor- Trends in under-five mortality by region tality in Sri Lanka and Malaysia. In Uganda Deaths per thousand Deaths per thousand and Thailand government efforts changed 250 250 sexual behavior, reducing the prevalence of Sub-Saharan Africa HIV. In low- and middle-income countries 200 200 services promoting oral rehydration therapy led to a decrease in diarrhea-related child 150 South 150 366 Asia mortality. Latin America and the Caribbean Health services also help protect the income 100 100 East Asia of the poor. Locally managed financing 50 50 and the Pacific schemes in Niger, contracted-out services in Eastern and Central Middle East and North Africa Cambodia, and insurance schemes targeting Europe 0 0 poor people in Thailand and Indonesia helped 1970 1985 2000 2015 1970 1985 2000 2015 reduce out-of-pocket spending and extended 367 Source: World Development Indicators database (2003). the reach of the safety net among the poor. (c) The International Bank for Reconstruction and Development / The World Bank 17_WDR_Ch08.qxd 8/14/03 9:45 AM Page 135 Health and nutrition services 135 Health services, when they work, can also Figure 8.2 Reaching the MDGs in health: focus on poor households contribute to greater self-reliance and social Stunting prevalence among children 3–5 years old, by inclusion of poor people. They have been used wealth group as entry points to broader development activi- Richest fifth ties, as in the Democratic Republic of Congo, Peru where community health financing schemes Second richest triggered the emergence of cooperatives to Morocco 368 commercialize agricultural products. Middle fifth Turkey But those who need the most often get the least . Ghana Second poorest Despite these successes the availability of good Kazakhstan health services tends to vary inversely with Poorest fifth need.369 Poor groups and regions have less 01020 30 40 50 access to sanitation and vector control.370 An Percent analysis of 30 countries shows that the use of Source: Analysis of Demographic and Health Surveys, 1990–2002. health care interventions is consistently lower among people living on less than $1 a day than among richer groups (figures 8.3 and 8.4).