ORIGINAL RESEARCHPoverty status and health equity: Evidence from rural Bangladesh
Introduction
No country in the world seems to be immune to health inequalities, but the increasing concern is that the health gaps between different social groups are widening worldwide. Eyob Zere and McIntyre1 reported higher usage levels of doctors and hospital services by the rich, relative to their levels of reported illness, in South Africa. Socio-economic, geographic, residence and gender divides in the use of immunization services are widespread in Bangladesh.2, 3, 4, 5 Ethnic disparity in the use of preventive and promotive health services is also evident6 and is a serious concern.
To address the particular health needs of the Bangladeshi poor, a host of non-government organizations (NGOs) have been trying to reach the poor with basic health services. However, they tend to address only the needs of the poor who participate in their development interventions, while those who do not or cannot participate are often excluded. Moreover, the poor are not a homogeneous group. Thus, there seems to be a large disparity among the poor in accessing health services, and this has been relatively unexplored. In fact, the health of these disadvantaged groups is extremely sensitive to the socio-economic and political development of Bangladesh.
Many researchers have attempted to examine the socio-economic inequalities in health in Bangladesh. Mannan7 analysed inequity in health by background variables, e.g. land, and found that 84% of the rural landless women did not eat any special food during their last pregnancy or whilst breastfeeding. The Bangladesh Bureau of Statistics (BBS)8 and Rahman et al.9 divided the households into poor, medium and rich, and thus found a wide gap between the poor and the rich in terms of usage of different health services. Analysing by wealth quintile, Gwatkin et al.5 found that uptake of childhood immunization was lower among the poorest people in Bangladesh.
Sen and Begum10 subdivided the poor into extreme poor and moderate poor. This analysis revealed a disparity in health among the poverty groups. The Millennium Development Goals emphasize the need to reduce health inequalities between different social groups, but Gwatkin11 argued that unless the special needs of the extreme poor and moderate poor are effectively addressed, the achievement would be at stake.
However, alongside the government, many NGOs have been trying to improve the quality of lives of the poor in Bangladesh by organizing them into development groups and giving them various services, including health services. It will be interesting to see whether the health gaps have narrowed between different poverty groups as a result of these pro-poor interventions, and if so, how did this happen? This study explored the status of health inequities among different poverty groups in rural Bangladesh.
BRAC (Bangladesh Rural Advancement Committee) is an innovative NGO concerned with growing health inequalities and their consequences. In order to offer health services to those most in need, BRAC has initiated health programmes in many parts of Bangladesh. The RHDC programme, which covers over 9.7 million people, was the successor to BRAC's earlier Women's Health and Development Programme (WHDP), which was implemented between 1992 and 1996. The RHDC directly offers a wide range of health services such as pregnancy care, reproductive tract infection, sexually transmitted diseases, education on human immunodeficiency virus/acquired immunodeficiency syndrome, adolescent reproductive health education, nutritional supplementation for children and pregnant women, community-based control of acute respiratory infections and tuberculosis, and deworming. The RHDC also facilitates a number of government services for more equitable access to its services such as satellite clinics, EPI, family planning, vitamin A capsule distribution, water and sanitation. In addition, BRAC Health Centres (BHCs) offer all primary and secondary clinical support and referral services: outpatient counselling, consultation, treatment, drugs, microscopic and non-microscopic laboratory services, sexually transmitted diseases/reproductive tract infection services, safe delivery, menstruation regulation, postabortion care, and other domiciliary care. Initially, the BRAC health services were open to all members of the community. However, in August 1997, BRAC shifted its approach to focus on the pressing health needs of the poor, especially those who joined the NGOs' microfinance activities including BRAC, to improve human capital and productivity, and to prevent income erosion stemming from different health emergencies.
Many NGOs including BRAC provide microcredit (small loans for income and employment generation) services to the poor in Bangladesh for poverty alleviation. BRAC identifies poor households that fulfil the following criteria: (i) a household with less than 50 decimals of cultivable land; and (ii) any adult household member sells manual labour for at least 100 days a year for survival, and forms groups with them in each village. These groups are designated as village organizations (VO), whilst the households who do not fulfil the above criteria are known as non-target (NTG). The VOs are given training and microcredit for poverty alleviation. BRAC spent over US$153 million, 20% of which came from donors' contributions.
Between 1991 to 1996, BRAC/WHDP provided services free of charge. Since 1997, BRAC/RHDC introduced service charges towards financial sustainability. The extent of charges varies by the type of services and the socio-economic conditions of the recipients (Table 1). VO members are charged Tk 10 (57.5 Tk=1 US$) for a consultation fee, whereas NTG members are charged Tk 20. Required drugs are sold to everyone at cost price. For each encounter of antenatal care, a VO member pays Tk 10 and an NTG member pays Tk 15. For each child delivered at a BHC, both VO and NTG members are charged Tk 250. Tk 140–160 is charged for menstruation regulation. BRAC also produces and sells slab latrines at Tk 140–160 per set. BRAC does not provide immunization directly; VAC facilitates these government services. However, regardless of VO membership, BRAC gives the extreme poor a 20% subsidy on the total costs incurred in every encounter. In addition, the extreme poor who are unable to pay are given free services.
A similar package of services is also available at the government facilities, and these are mainly free of charge. The poor have no easy access to these services due to distance and unacceptable behaviour of the providers. In addition, there are hidden costs involved in availing these services which sometimes surpass the market costs.12 Moreover, the quality and availability of necessary services at government sources are poor. This study, as part of a more comprehensive study on the impact of the RHDC programme, focuses on the equity aspects of different health service users in two rural RHDC areas.
Section snippets
Study area and sample design
Employing a multistage sampling method, 80 villages of the Bogra and Dinajpur sadar thanas (subdistricts) were chosen for this study. A total of 4003 households were surveyed using a cluster survey method between May and July 2000 in order to collect data on mortality and fertility. Health-service-related data were collected from a subsample of 1032 systematically selected households (25% of total).
Primarily, responsible and competent mothers were interviewed using a pretested standard
Use of pre- and postnatal services
Table 5 depicts that less than one-tenth of deliveries among different groups of the poor took place in hospitals and/or clinics (termed ‘institutional facilities’) (extreme poor 9.3%, moderate poor 8.6%), compared with over one-quarter for the non-poor (26%) (p<0.001). The proportion of moderate poor mothers (34.6%) who had been ill during their last pregnancy and who received treatment from qualified/trained physicians was lower than that for the extreme poor (50%) and the non-poor (72%). The
Discussion
Overall, the data primarily revealed varying degrees of inequities in key health indicators among all the study groups. When comparing the extreme and moderate poor separately against the non-poor, the degree of differentiation across various health indicators was even greater. This may be the general trend in countries where equity objectives are not set or no policy mechanisms exist for increasing health equity.
In fact, while examining different indicators by poverty status, the data
Conclusion
In conclusion, this study demonstrated health inequities between different subgroups within the poor and the non-poor. In particular, the use of services/facilities that require payment by the user was low among both groups of the poor, implying that they are unable to afford these. The moderate poor appeared to be considerably better in many study indicators compared with the extreme poor. However, a propensity of narrowing the gaps between the poor and the non-poor in some indicators such as
Acknowledgements
The authors are grateful to BRAC's Health, Nutrition and Population Programme for financing the study out of a donation received from the Department for International Development, UK. They are very appreciative of the assistance given by Dr Shantana R Halder, Senior Research Economist of BRAC Research and Evaluation Division (RED) in various stages of the study. They would also like to thank the field investigators who worked in adverse conditions for data collection, and the respondents for
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