THE POOR SPEAK OUT
Bank-supported project Voices of
the Poor vividly illustrates how poor people
link poverty to high fertility and gender
From Ghana: "Poor men and women
across the communities visited … consider
lack of money, unemployment, and having
too many children as leading causes of
poverty. Other causes mentioned in most
communities relate to low crop yields and
soil infertility, and to diseases and ill health.
… [In listing] the impacts of poverty, every
single community mentions poor health or
premature death…. In five communities,
prostitution is identified as an impact….
Poor people often speak of their large
households and the added stress this can
place on meager resources and social relations.
In almost every [description of] the
causes of poverty, women and men have
included 'unplanned births', 'lack of family
planning', or 'too many children'."
From Malawi: "Study participants in two
urban settlements … say that some households
are doing better because family
planning is now more available. According
to a poor woman in Chemusa, 'In the past,
people were not using family planning
methods and this was causing the families
to have more … so that it was difficult for
most households to budget properly'."
From Jamaica: "A woman … speaks for
many others when she explains that a
woman must have her own economic
means so that 'she doesn't feel helpless'.…
Many women … acknowledge their drive
for financial independence and express
appreciation for the greater freedom that
having an income brings…. Other women
advise, 'Have your own shelter and finances
so you don't have to stay in an abusive relationship.'
… A woman in Cassava Piece
remarks, 'More women work now, so they
don't have to put up with men's foolishness.'
In some urban communities women
mention greater freedom to choose family
planning methods." See Sources
Health care reform often means decentralization, so that local
services can respond to local needs. Effective reform depends on
guaranteed funding-by providing more resources and better use
of available funds-and central support for services that cannot
be supplied locally.
Health systems focus on treatment and cure, so specific action
is needed to protect preventive services like reproductive health.
Partnerships with NGOs and the private sector can be productive.
Decentralized systems can pay more attention to inequities
in health service delivery. Affordable service fees can be used to
improve the quality of care, but the poorest cannot afford
fees at any level. Fees have meant that millions of poor people,
particularly women and children, forgo the care they need.
Health issues are discussed in Chapter 5
HIV/AIDS Poverty, inequality and globalization combine to
increase the impact of the pandemic. It is the major cause of death
in Africa, where 28 million live with HIV/AIDS: all but 1.5 million
of the 40 million currently infected people live in developing countries.
It is spreading fastest in Eastern Europe and Central Asia,
and is daily becoming a more serious threat in India and China.
In 2001 three million people died of AIDS, out of 22 million the
disease has killed. AIDS deaths have left 13.4 million children
without one or both parents, a third of all orphans. For the poor,
this means increasingly relying on the grandparents' generation,
but older people are often unable to cope. An increasing number
of poor children are without any kind of family support.
POVERTY SPREADS HIV/AIDS Malaria, tuberculosis and sexually
transmitted diseases that predispose to HIV infection are more
common among the poor. Poor people know less about HIV/AIDS
and are less able to protect themselves. Young women are especially
vulnerable, and especially uninformed-in one African country
nearly nine out of ten sexually active teenagers know nothing
about HIV/AIDS. The impact of AIDS further impoverishes the families
HIV/AIDS is a demographic, social and economic disaster. As it
kills predominantly younger adults, the worst-affected countries
are seeing the hollowing out of an entire generation in the productive
age group, with all the attendant consequences: personal
tragedy, families forced deeper into poverty, communities threatened,
the social fabric weakened and now looming economic crisis.
In the worst-affected countries public servants and private
sector employees are falling sick in increasing numbers. By 2020
economies could be 20-40 per cent smaller than expected because
of the pandemic. Damage to public services such as education and
health will drive the poor further into poverty. Health services
have already moved out of the reach of many of the poorest because
of fees for service and other charges. Education can provide a
"social vaccine", but education and health systems are both collapsing
as teachers and health workers die.
The pandemic shows no signs of slowing. Instead it is threatening
to engulf the most populous countries of the world, India,
China and Indonesia. Effective leadership has held back infection
in countries such as Senegal, Thailand and Uganda, but many
leaders at all levels have not yet confronted the pandemic. Despite
many statements of support, members of the international community
have not yet provided the resources poor countries need.
The disease spreads overwhelmingly by unprotected sexual
contact, predominantly between men and women. About a third
of infected mothers pass the disease to their children in utero.
Women are more vulnerable to infection for physiological and
social reasons, and sex workers are far more likely than the population
at large to be infected, but the sexual behaviour of men is
largely responsible for spreading the disease.
Half of all new HIV infections
are among young people aged 15-24, and young women are
more likely to be infected than young men their own
age, reflecting their social vulnerability. Young people
are ignorant of the disease and its effects, and do
not know how to protect themselves against it. Many
societies still do not consider this information suitable
for young people, despite ample evidence that the exercise
of sexual responsibility, including abstinence, depends
at least in part on accurate and timely information,
and that young people will use sexual information and
services in a responsible manner (15).
Stopping the pandemic means stopping the spread of infection.
Prevention calls for adequate information and services, which
should include emphasis on abstinence outside marriage and
fidelity within it. Treatment can help, but any cost is too expensive
for the poorest people. There must be adequate supplies of male
and female condoms, and the motivation for people to use them. At
present, only one person in five has access to information and
services to protect themselves against infection.
Calls for "behaviour change" alone
will not motivate people to protect themselves, or enable
them to do so. HIV/AIDS accompanies poverty, is spread
by poverty and produces poverty in its turn. The infection
spreads rapidly among people without confidence in the
present or hope for the future.(16)
Effective strategies to turn back
the epidemic must go beyond medicine and health care
and reach into the community. They call for close consultation
with the people they seek to assist(17).
Strong and committed leadership that leads by example
as well as exhortation is a prime necessity.
The Global Fund for AIDS, Tuberculosis and Malaria will do
much to combat the pandemic, if the international community
provides the required funding.
HIV/AIDS is discussed in Chapter 6.
EDUCATION AND POVERTY Access
to basic education as a human right has improved, but
there is much more to be done. The poor have benefited
less than the better off. The push for universal primary
education has left out poor children. Rural/urban differentials
remain large in many countries (18).
The content and quality as well
as the level of education affect children's prospects
for development. Educated mothers encourage and support
the education of their children (19).
They know the value of education, but they are also
able to afford it. The poor cannot afford to supplement
inadequate public systems with private education.
The number of siblings can affect a child's chance of education:
poor families must often choose which of their children to
educate. In extended families, relatives sometimes step in to cover
some of the costs, but the choice falls more often on the boys,
leaving the girls with little or no education. Parents may also have
concerns about girls' safety at school, or going to and from school.
Among older girls, pregnancy is always a risk. Even without these
pressures, mothers' need for help with their many tasks often takes
priority over girls' schooling. The gender gap in primary education
has narrowed in many countries over the past several decades, but
sometimes this is only because boys' progress has slowed.
Many children do not have the benefit of a two-parent family.
The luckier ones are living in one-parent homes or fostered with
relatives, but a large and growing number of children are abandoned,
orphaned (increasingly by HIV/AIDS) or sold into sexual servitude.
Thier lives aer likely to be short, painful and unhappy.
Education for the children of the poor, especially those who
live outside the reach of families, calls for special efforts. Civil
society helps reach out to young people outside the school system,
but efforts are piecemeal in most developing countries. It requires
a massive investment in both formal and informal education,
inside and out of school.
HEALTH AND EDUCATION Educated mothers have healthier
children. They know more about good nutrition, and there is less
competition for food in smaller families. The combination accounts
for 43 per cent of the reduction in child malnutrition between
1970 and 1995.
Educated women have fewer children, and fewer unwanted or
mistimed births, but other influences help produce this effect.
Educated women tend to come from educated families, and they
know about and use health care and family planning. Education
may stimulate the desire for better health care and smaller
families, but education is neither a clinic nor a contraceptive.
Women need services to give effect to their wishes and meet
With fewer children, families can
invest more in each child's education (20).
Unwanted children will have less education if parents
must pay for it, as they increasingly must (21).
Education is discussed in Chapter 7.