Population, Poverty and Global Development Goals: the Way Ahead
COOPERATE FOR EFFECTIVENESS Governments, communities,
the private sector and the international community must cooperate
to make best use of their comparative advantages and reduce
duplication, waste and inefficiency. This has been a common call
for many years, but the battle against extreme poverty has given
it new emphasis.
GOVERNMENTS' ROLE National action to improve the health
of the poor and reduce health inequalities includes:
economic policies that contribute to poverty decline;
information on health and health services;
- control of infectious diseases;
- legislation for better health;
- subsidized health services for the poor;(2)
The World Health Report 2000 calls
for governments to be better stewards of the public
health and of health care resources, particularly to
benefit the poor (3).
Meeting the ICPD consensus goal
of universal access to reproductive health care by 2015
requires safety net systems-free services, subsidized
care, insurance schemes and sliding-scale fees-to ensure
that the poor clients receive reproductive health care.
"The ICPD agenda helps frame the issue of health financing
in terms of client needs and empowerment. The question
that needs to be asked by any policy initiative is,
will it hurt the poor and will it discriminate against
NATIONAL POVERTY REDUCTION STRATEGY PAPERS The World
Bank and the United Nations system, including UNFPA, are
coordinating their assistance for development in the poorest countries.
An important tool is the national Poverty Reduction Strategy
Paper (PRSP), which outlines national priorities and action
plans following broad-based and participatory analyses led by government
and national stakeholders, including civil society groups,
parliamentarians and the private sector.
These plans are recognized as an important vehicle for progress
towards the MDGs. Regularly reviewed, they will serve as the basis
for implementation and monitoring. The plans can be the basis
for debt relief under the Highly Indebted Countries Initiative for
candidate countries, and for concessional lending in others.
Many countries have already developed papers preliminary to
the broad exercise (called interim PRSPs) or completed their plans
and started the continuous process of implementation, monitoring
Analyses of the process conclude
that many of the plans being developed are analytically
sound and practical. However, further improvements are
needed to build national capacity and ensure fuller
participation by a broad range of national stakeholders
(5). The participatory
person-directed approach to development promulgated
in the ICPD and other international conferences has
advanced significantly in the past decade, but continued
improvements will be required.
A UNFPA review of 44 interim PRSPs
showed that improvements are also needed to ensure the
fuller incorporation of population, reproductive health,
gender equity and human rights concerns (6).
UNFPA will be giving higher priority to coordinated
development, including PRSPs, health sector reform,
sector-wide approaches and UN system Common Country
Assessments, and in civil society outreach, in order
to redress such omissions.
LISTENING TO THE POOR ON HEALTH
A study for the
World Development Report listened to the poor in 23
countries as they talked about the effect of poverty on their
lives. Author Deepa Narayan offers five suggestions based on
the study, Consultations with the Poor.
First, protect the poor against the financial shocks of ill
health. Far too many poor people must choose between saving
family members who are sick and feeding the rest. Design better
ways to protect against catastrophic illness, building on the
experiences of institutions like India's Self-Employed Women's
Association and Bangladesh's Grameen Bank.
Second, provide effective health infrastructure where the
poor live. Water and sanitation are particularly important,
especially in South Asia where poor women are deeply fearful
about having to go long distances for water.
Third, improve the behaviour of health care providers
in public facilities. The rudeness of some government
health care providers helps explain why the poor avoid government
Fourth, combat domestic, gender-based violence. The
effects of violence on women are a public health concern.
Fifth, recognize the psychological as well as the physical
impact of HIV/AIDS. Among the poor, especially in Africa,
AIDS means stigma and shame, as well as suffering.
DIRECTING PROGRAMMES TO REACH THE POOR Closer attention
to poverty alleviation demands that programme benefits reach poor
The ICPD Programme of Action lists a number of good
examples of services targeted directly to the poor. UNFPA has led
interagency policy discussions on basic social services, acknowledging
the social service orientation of the Programme of Action.
Effective population and reproductive health programmes focus
on individual service and information needs. The principles
of service orientation are already well established in the area
of reproductive health, but health services must also reach the
poor with prevention and treatment of important
Effective reproductive health programmes for the poor depend
on listening to their opinions and involving them in programme
design and delivery. This is especially important for women,
who have the most to gain from population and reproductive
It is not enough to steer technical and financial assistance
to the poorest countries: programmes within countries must direct
domestic and international resources to the poorest of the poor.
They must have protection, support and a voice.
The basic principles are simple:
target services to reach the poor;
reduce costs to the poor;
- give the poor a voice in the design, implementation and
monitoring of programmes;
- provide public assistance for public goods, including services
with large indirect effects;
- stress prevention-it is cheaper than cure (often in both the
long and short run);
- improve the quality of services;
- improve data that monitors what the poor need and what
- advocate for programmes to reach the poor and improve the
data used to provide services and mobilize needed resources
- reduce inefficiencies and inequities.
Analysts identify four means of
directing health resources to the poor: (7)
- Address the burden of disease: see that resources address
health conditions for which the burden of disease is high
among the poor;
- Provide basic social services: give priority to basic social
services, primary health care, prevention and basic curative
services plus health promotion and essential surgery;
- Direct resources to poor areas: provide attention to rural and
poor peri-urban areas, remote populations and slums;
- Direct resources to the poorest households and communities:
protect the poorest from a cost burden they cannot meet.
REPRODUCTIVE HEALTH Better reproductive health
is important to improving the health of poor people. Conditions
related to reproductive health account for half of the top 10
causes of the disease burden among women of reproductive age.
The burden is markedly higher among poorer and higherfertility
Of all income groups, the poor have the least access to reproductive
health information and services and the greatest exposure
to risk. The poor tend to want larger families than the better off,
but they also have more unwanted and unintended pregnancy.
High levels of unintended pregnancy result in even higher levels of
actual fertility than desired. This increases the need for antenatal
care and safe delivery services and for quality family planning
services to reduce unwanted pregnancy and recourse to abortion.
Improving the quality of reproductive
health services is the key to improving their accessibility
and usefulness to poor people (8).
Officials often abuse or mistreat poor clients, who
do not have the information or confidence to question
their treatment or the price of service. Quality depends
on a reliable supply of drugs and commodities, as well
as on good training and supervision. Technical competence
is important, and it is also important that staff respect
users' personal dignity, respond to their questions
and approach them as individuals with diverse needs
and cultural backgrounds.
COMMUNITY PARTICIPATION Religious and charitable
institutions, including places of worship, schools, hospitals, food
delivery systems, hospices and teaching or pastoral care, often
provide what services there are in poor communities, particularly
where public services are absent or inaccessible.
The population and women's conferences in 1994 and 1995
called for increased community participation, and particularly for
giving women and other marginalized groups-the very poor,
adolescents and people living with AIDS-a voice in the community
and in development activities. Strong civil society organizations
can help this process.
Decentralizing health care can help community involvement,
but for decentralization to benefit the poor, poor people themselves
must be involved in setting priorities. Direct involvement of parents
and community leaders is especially important for discussing
and addressing adolescent reproductive health problems such as
teenage pregnancy and HIV/AIDS prevention.
Advocates are working to ensure
that reproductive health needs do not get lost in decentralized
systems (9). They
have called for universal access by poor women to safe
motherhood services, including emergency obstetric care,
for example, and for equitable treatment of people living
with AIDS. Community movements have sprung up to provide
support for members affected by HIV/AIDS, particularly
orphans, despite the stigma and discrimination associated
with the disease. Community insurance and health support
systems can help women especially to protect themselves
from risks and gain access to needed services-for example
emergency transport for pregnant women who have difficulties
in labour. An active civil society can create a supportive
environment for community action (10).
MEETING SPECIAL NEEDS The
ICPD Programme of Action called for better population
and development programmes, while ensuring their accountability
to the most vulnerable and disadvantaged groups in society,
including the rural population and adolescents (11).
It stressed that population-related programmes contribute
to the empowerment of women and improved health, especially
in the rural areas, along with other benefits (12).
It called for particular emphasis on meeting the reproductive
health needs of underserved population groups, including
adolescents, "taking into account the rights and responsibilities
of parents and the needs of adolescents and the rural
and the urban poor" (13).
RURAL AND OTHER UNDERSERVED
POPULATIONS Experience shows that poverty reduction
depends on the success of rural development programmes
(14). Poor people
in rural areas still have a higher level of unmet need
for family planning services, and resulting unwanted
fertility, than people in urban areas. This contributes
to population pressures on local environments, driving
migration to overcrowded cities and the areas around
The five-year review of the Programme
of Action encouraged countries to ensure that assistance
from international donors is invested to maximize benefits
to the poor and other vulnerable population groups (16).
URBAN MIGRANTS Though cities
overall have better social services than rural areas,
urban slums and shanty towns are often neglected. So
are medium-sized cities, which are growing relatively
rapidly (17). They
provide local markets and services, and link the countryside
to the larger agglomerations; yet they receive relatively
little central support and lack the authority to raise
funds through taxes and charges. Increased attention
is being given to discovering where the poor are concentrated,
in order to direct services, subsidies and other resources.
REFUGEES AND DISPLACED PERSONS Among the poorest
of the poor are people driven from their homes by natural disaster,
political upheaval, social strife and war. They often live in
temporary camps where social services are minimal, and international
assistance provides whatever help is available to meet
immediate needs and plan for resettlement.
Three quarters of displaced and refugee populations are women
and children. Twenty-five per cent are women of reproductive
age. One in five is likely to be pregnant. They may have suffered
rape or assault in their homes or as they fled. Sexual violence
and exploitation in refugee camps is all too common. For these
women, already suffering, childbirth is even more risky than
it would be at home, unless some basic services are available. They
may need counselling and psychological support.
Reproductive health services for populations in crisis take
their place with food, shelter, water and physical safety. They
save women's lives. They are essential for health and dignity in
UNFPA provides support in emergencies, focusing on:
- safe motherhood through clean delivery, family planning and
emergency obstetric care;
- family planning information and services;
- prevention and treatment of reproductive tract infections
- prevention of HIV/AIDS, including information on universal
- adolescent health;
- prevention and treatment of sexual and gender-based
ADOLESCENTS There are now more than 1 billion young
people between the ages of 10 and 19 in developing countries, the
largest such group in history. This age group is expected to
become bigger at least through the middle of the century, increasing
by another 174 million by 2050. These young people are the
productive workers and the parents of the future-but they need
information and skills to protect their lives and health and
fulfil their potential.
At international meetings, young
people repeatedly call for respect, encouragement and
nurturing as they grow to adulthood. Young people have
expressed their needs wherever and whenever they are
given a chance-at regional meetings of adolescents (19)
and at the United Nations Special Session on Children
in May 2002 in New York.
Young people's access to reproductive health information and
services has been restricted-even if they are married-and
the topic has been extremely sensitive. But their needs can be met
with appropriate and age-sensitive involvement of parents, families,
friends, cultural leaders, communities and peers. Apart
from formal schooling, young people need education which reflects
the complexity of their lives, including livelihood training,
entrepreneurship, negotiation skills, gender equity, health and
nutrition-all aspects of preparing for adulthood.
MICROCREDIT, SOCIAL INSURANCE AND REPRODUCTIVE HEALTH
micro-finance programmes have included
from their inception family planning, child
nutrition and health and related activities.
In Bangladesh, Grameen Bank, BRAC and
other NGOs encourage their members to
discuss and adopt family planning. Pro
Mujer in Bolivia and schemes in other Latin
American countries do the same.
Group-based insurance schemes often
seek to provide social protection such as
health insurance to their participants, subsidized
from the returns on loans. Groups
decide which services they need, depending
on participant priorities and on the
terms they can negotiate.
In francophone countries in western
Africa there were 360 insurance and credit
schemes by 2001, covering 1.25 million
people, a seven-fold increase since their
start in 1988. Increased coverage has
improved their negotiating position.
One insurance group contracted with a
service to teach mothers in the group how
to stimulate cognitive ability in their children.
One client, impressed by the intensity
and duration of the suggested exercises,
concluded, "If we need to do all this work
with our kids, we can't have more than
two." The group subsequently added family
planning services to its offerings.
Researchers attribute members'
increased use of modern family planning to
better information and the mutual support
that women give to each other's choices.
Increased decision-making power within
the family and changes in women's status
take longer to develop.
MICROCREDIT Deep poverty reaches into all areas of life. Many
needs interlock: health is a matter of housing, nutrition, clean
water and sanitation as well as health services. Integrated
approaches empower people to set their own courses out of poverty.
Microcredit schemes are among the most effective means to
empower the poor, and particularly poor women, for economic and
social advancement. The amounts of money lent are typically small,
usually less than $100. Group-based schemes encourage members
to work together and support each other, and have become popular
with donors partly because they have a very good track record
in repayment. They often include other services such as literacy
and family planning.
The Microcredit Summit of 1997
adopted the goal of extending credit for self-employment
and other business services to the 100 million poorest
families, and particularly to women. Special attention
would be given to reaching the poorest in each country.
In 2000, microcredit reached nearly 31 million clients,
over 19 million in the poorest households and over 14
million of the poorest women (20).
The International Microcredit Campaign has developed "tool
kits" to measure household poverty and identify the poorest households.
Tools include a Participatory Wealth Ranking that uses
community informants to identify poor households and the CASHPOR
House Index of a common set of household characteristics.
Training and dissemination are increasing, particularly in Africa
Micro-finance has showed women how to earn money, but
there is still the question of who controls the resources they bring
into the home. Male partnership is not guaranteed, and some men
feel threatened by their wives' new earning power.
BETTER MONITORING AND DATA SYSTEMS The poorest countries
need to improve data systems for monitoring progress towards
the MDGs. UNFPA is working with partner institutions of the UN,
the international financial institutions, bilateral donors and foundations
to strengthen national monitoring capacity.
UNFPA has long experience in supporting population data
collection. The Fund has moved from broad support for countries'
first censuses to providing specialized technical assistance. In
many low-income developing countries UNFPA acts as the coordinator
of UN system support in the area. In 2000, Cambodia gave
the UNFPA representative one of the nation's highest honours for
assistance with its first census after decades of political instability.
UNFPA helps countries collect information to develop policy
responses to emerging issues, for example the impact of the 1998
economic crisis on reproductive health in South East Asia, and
the quality of life of older people in India and South Africa.
UNFPA has assisted censuses and
surveys in refugee camps and other post-conflict settings.
It has joined in UN system-wide support to census and
statistical organizations in many emergency situations.
It has encouraged qualitative research (21),
for example, studies of reproductive health, gender
violence and related issues among internally displaced
persons in Angola. UNFPA support helped establish and
publicize the extent of rape and assaults on women in
the former Yugoslavia during the wars of the 1990s,
so that the women could get help. The Fund is assisting
the development of data collection and data-based policy
development in East Timor.
Demographic and Health Surveys
funded by UNFPA and other donors are important for monitoring
mortality, fertility, health, poverty and service access,
and showing where improvements are needed (22).
They have provided practical methods to estimate wealth
to help poverty-related policy research (23).
IDENTIFY DATA NEEDS As programme staff, researchers, policy
makers, NGOs and other users clarify their data needs, UNFPA
will promote integrated approaches to assessment. For example,
the Fund may suggest including key demographic and behavioural
measures in economic and other surveys, improving the gendersensitivity
of data collection systems and indicators, and combining
different measures in databases intended for policy makers.
With decentralization, municipalities or districts are making
decisions about priorities in development plans and local health
delivery. These local bodies need access to local data and training
in its use to make evidence-based decisions on policies and
programmes. UNFPA provides support to empower local decision
makers and give them accurate and timely information on
which to base decisions about priorities in reproductive health
and gender empowerment.
They will use the improved data together with direct inputs
from affected populations to target interventions and make
financing decisions and formulate responsive strategies.
LIMITATIONS OF THE DISABILITY ADJUSTED LIFE YEARS MEASURE
National health systems and decentralized
health committees alike often base their decisions about what
to offer in basic or essential service packages on measures
that do not fully reflect the impact of reproductive health. The
widely used Disability Adjusted Life Years (DALYs) measure,
for example, estimates the impact of a disease or condition in
terms of an individual's lost quality of life. However, various
technical features of this measure underestimate the importance
of reproductive health:
- The disease-oriented approach doesn't address conditions
that affect life quality and health but are not
diseases, for example unwanted pregnancy;
- The loss of mothers' lives from unsafe abortion is reflected
in the measure, but not the public health implications
of preventing unwanted pregnancy and abortion through
safe and effective family planning;
Less weight is given to lost health among people older
than 25 than in younger groups, discounting health
effects in most of the reproductive years (15-49);
- Impacts of a person's disease on other family members
(on the children of an ill mother, for example) are not
- The experts who determined the severity of various conditions
and the weights assigned to them were mostly
from developed countries-where reproductive morbidity
is less common-and included few women.
Census data make it possible to
draw "poverty maps" on which poor neighbourhoods show
up. This helps in placing service delivery points and
outreach systems for the broadest possible coverage
(24). In addition
to improving data on demographic trends and quality
of life, countries need better data on the benefits
and costs of programmes, where the resources for them
come from and how they can be more effectively used.
EUROPEAN UNION DECLARATION ON HEALTH
In May 2002, following the
United Nations Special Session on
Children, the European Union Development
Council reaffirmed its commitment to the
continuing international consensus on priorities
in assistance to health, stressing the
importance of universal access to reproductive
health services and rights.
"The EU reconfirms its firm commitment
to contribute to ensuring that by
2015 the death rates for infants and
children under the age of five years in
developing countries is reduced by two
thirds; the rate of maternal mortality is
reduced by three quarters; universal access
to reproductive health care and services is
provided for all individuals of appropriate
ages, consistent with the commitment and
outcomes of the International Conference
on Population and Development (ICPD)
and other UN conferences and summits;
the spread of HIV/AIDS and the incidence
of malaria and other major diseases is halted
and begins to be reversed."
The European Union further indicated
that over the next five years, the EU will
increase the volume of development assistance
targeting improved health outcomes
and will invite recipient countries and the
international community to join them in filling
the financing gap to meet the
Millennium Development Goals. They
emphasized that in supporting health programmes,
particular attention will be paid
to communicable diseases, maternal health
and to reproductive and sexual health