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HOME: STATE OF WORLD POPULATION 2002: Population, Poverty and Global Development Goals: the Way Ahead
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Population, Poverty and Global Development Goals: the Way Ahead

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Recommendations for Action

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 women?" (4)


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 and revision.

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.

25 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 services.

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 people directly.

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 communicable diseases.

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 health programmes.

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 they get;
  • advocate for programmes to reach the poor and improve the data used to provide services and mobilize needed resources and support;
  • 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 populations.

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 them (15).

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 extreme situations.

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 and STIs;
  • prevention of HIV/AIDS, including information on universal precautions;
  • adolescent health;
  • prevention and treatment of sexual and gender-based violence (18).

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.

26 MICROCREDIT, SOCIAL INSURANCE AND REPRODUCTIVE HEALTH

Several 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 and Asia.

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.

27 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 included;

  • 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.

28 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 and rights.



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