Activity 4: Poverty and Health

PI: Dr. Abbas Uddin Bhuiya

Monitoring Availability of Health Services

The Social and Behavioural Sciences Unit at ICDDR,B has been carrying out activities on poverty and health issues under the Improved Health for the Poor project. The three-year long activity devoted to development of a simple monitoring tool that measures the utilization of the health services by poor or any other specific group. These kinds of monitoring tools are of importance to programme managers in developing countries to asses the reach of their interventions to the populations they serve, especially the poor. The tool is based on the Lot Quality Assurance Sampling (LQAS) method, and allows the facility and programme managers to interview a small number of respondents (not more than 30) to decide whether a community is performing adequately in reaching the poor or any other special group. The level of adequacy is defined by a triage system of cut-off points with lower and upper limits for coverage of services. The tool can also be applied at the facility level to monitor whether the facility is serving the poor as much as it should.

These simple yet practical methods were developed and used in two Upazillas, Nabinagar and Sibalaya, to monitor the utilization of health services by the poor. Experience of applying the tool in two Upazillas showed that the Upazilla Health Centre and the Union Health and Family Welfare Centres are more pro-poor than private facilities. The LQAS methods are now ready for adoption in more Upazillas.

The results from this study indicating that public health facilities are more pro-poor than private health facilities mean that if we want to reach the poor effectively, we have to invest in the quality development of public health facilities.

Community Service Monitoring

The study also developed tools for establishing a health-watch by volunteer groups from the community at the union level and in the villages. Facilitation of local level monitoring of health services by the villagers has been carried out in one union in Chakaria, which will conclude in December 2007. The experiences in community monitoring and processes have been documented. Meanwhile, the community has become more aware of their health-related issues and health facilities in the community. The community has internalized a monitoring process to ensure they are receiving their due services from the Union Health and Family Welfare Centre, and is now able to successfully advocate and ensure better governance of the health facilities. There is also a high level of local government involvement for the health-watch.

The results of this pilot project will be documented in the form of a manual that can later be adopted to scale up the programme.

Reaching the Poor with Safe Motherhood Services

Chakaria community health project also has been testing the feasibility of reaching the poor with safe motherhood services from the skill birth attendants (ICDDR,B trained) through the use of vouchers. In this experiment the pregnant women from the lowest two asset quintiles have been provided with free vouchers to obtain ANC, delivery at home, PNC, and referral in case of complications. ICDDR,B reimburses the cost of the services provided to the poor on production of the vouchers by the skill birth attendants. This is showing an increased use rate of the safe motherhood services among the women from the lowest two asset quintiles. In addition a medical doctor also has been seeing patients in the seven village health posts established and managed by the villagers in six unions of Chakaria.

Inequalities in Service Utilization

The existing data on health care utilization was also carefully analyzed to better understand the extent of inequalities among socially and economically marginal groups. Our study results found from the Chakaria Health and Demographic Surveillance System (HDSS) data showed a statistically significant difference in health service utilization by the people from different economic strata. The gap is greatest in the utilization of safe motherhood services – with facility-based delivery among the women from the highest asset quintiles is 13 times more than the women from the lowest quintiles. This information will allow us to better understand our progress towards reaching the health-related Millennium Development Goals.

Poverty Measurement Tool

A poverty measurement tool consisting of indicators to assess shortfall in food, shelter, clothing, education, health, and social participation has been developed and tested. The administration of the tool takes only half an hour in the field. This tool incorporates the multidimensional nature of poverty and considered to be of more practical application than the conventional tools.

Collaborating Institutions:

• Ministry of Health and Family Welfare
• BRAC School of Public Health

Results:

• A facility based pro-poor monitoring tool has been developed and tested in three Upazillas Nabinagar, Shibalay and Chakaria
• Existing data on utilization of health services and demographic characteristics were analyzed with a focus on equity
• A tool to measure poverty with a multidimensional approach has been developed
• A model for establishing local health-watch that involves elected representatives of the union council has been developed
• A voucher system to monitor delivery of free safe motherhood services to the women from the lowest two quintiles has been tested
• Limited curative health services has been provided to villagers of (Chakaria) through seven village health posts
• A one-week health equity training course in collaboration with BRAC, World Bank Institute and ICDDR,B was held for government of Bangladesh, NGO and university representatives.