December 28, 2009

December 28, 2009
Failing the Poor

Welcome to another day in my life. Today is Monday and the start of another work week for most of us. I hope you are having a safe and great start to your week.

For many of you, the past week involved traveling to be with loved ones, family or friends. And it also included in most parts of the country a combination of higher security check at airports, snow, delays and layovers. So I hope everyone was able to enjoy their holidays and make it to their destinations.

But for many, it was a hard holiday season. Especially if you are poor. But being poor and having HIV is a deadly combination.

Despite the global health community’s best intentions, many health interventions meant to address the needs of the poor are instead being captured by wealthier sectors of the world’s population, resulting in further disparities in socio-economic and health indicators.

That is based on data compiled by the World Bank’s Dr. Abdo Yazbeck in his recent book Attacking Inequality in the Health Sector.

Speaking to delegates at the 40th Union World Conference on Lung Health in Cancun, Mexico last week, Yazbeck claims that while the “consistent and large gap between the health of the wealthy and the poor…is the motivation for spending on health based on the idea that health care providers can help to close this gap, poorly targeted spending may actually add to the problem.

Yazbeck demonstrates that public services are used more often by those in wealthier sectors of the population than by those most in need. In India, for example, the rich capture 33% of public health spending, with the poor receiving only 10%. People living in poverty are also less likely to receive services such as immunization and pre- and post- natal care.

Poor women and children are most at risk of being left behind: based on data from 56 countries, covering 2.8 billion people, infants in poor families are twice as likely to die before the age of 1, and children from poor families are three times more likely to face stunting and half as likely to receive full vaccination than their wealthier counterparts.

“The reality is not the same as the intention, the poor are capturing much less than they should. Consistently the health sector is simply not fixing this gap, and may in fact be making it worse,” Yazbeck said.

Dr. Francois Boillot of the International Union Against Tuberculosis and Lung Disease reiterated Yazbeck’s concerns. “Do you know how much money is spent on health per capita per year? In poor countries it is in the range of $20 in higher income countries it is in the range of $2000.

“In low income countries,” Boillot continued, “80% of this $20 comes out of the individuals pockets, while in wealthy countries, only 40% of health expenditure comes from individuals pockets.”

In order to ensure that the poor receive a greater proportion of health services, Dr. Yazbeck suggests “pro poor reform,” in which not only the needs but also the wants of the poor are addressed, making services more accessible.

He also advocates for universal health insurance and decreasing health fees, especially for the poor; providing incentives for health care services to cater to the poor; addressing logistical concerns such as access to transportation and nutrition; and including the poor in the planning and implementation of services.

Dr. Yazbeck points to several successful pro-poor initiatives taking place around the world, stating that while there is an ocean of inequality there are islands of success. The trick is to identify these islands, and apply them.

Dr. Joia Mukherjee of Partners in Health advocates for stronger community-based strategies in order to address health inequalities and ensure that interventions reach those who need it most. “Without a very strong community-based strategy, we are not going to make a dent on tuberculosis,” she says.

According to Mukherjee, the money allocated by international donors as well as domestic governments must be better spent, shifting away from a clinic centered approach.

“The disease and the illness and the social determinants are happening at the community level, and if we just focus on case finding and passive care, we are not going to win,” she insists.

“It is a different approach to be managing disasters [when you] have people in the community who are informing and participating in the work.”

Boillot’s suggestion is more direct: “we need to learn to spend money on the poor.”

Those are my thoughts. What about yours? Drop me a line and let me know.

Until we meet again; here's wishing you health, hope and happiness.

big bear hug,

Daddy Dab