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p. 15 of 27 BACK | NEXT Executive summary Introduction Regional health context The Bank’s involvementin the health sector Issues and options The health of the poor, women, and indigenous peoples Setting clear priorities Mobilizing resources for the public health sector Building managerial capacity Testing innovative approaches Introducing effective, new, and affordable technologies Focusing on functions which constitute public goods Increasing collaboration between public and private sectors The Bank’s health policy

Policy for the Health Sector : Issues and options

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The health of the poor, women, and indigenous peoples

Focusing on the poor

Alleviating the excess burden of disease borne by the poor can be accom plished in a number of ways, including (i) increasing physical access to services; (ii) focusing on the control of health problems that disproportion-ately affect the poor; (iii) increasing the resources available for health facilities frequented by the poor; (iv) measuring the performance of health care systems in providing services to the poor; and (v) employing more participatory approaches.

Increasing physical access to services. While there has been significant improvement in the last 35 years, many of the poor in the region still lack physical access to health services. One way of improving their access is to establish more health centers and small health posts, particularly the latter, in rural areas. Another frequently overlooked tactic is the use of outreach activities. Having health workers travel regularly to distant villages to provide preventive and promotive care is a simple but effective means of increasing the coverage of services for the poor. Provid-ing adequate travel allowances can act as a powerful incentive for health workers to visit outlying areas regularly.

Focus on health problems of the poor. Much of the difference in mortality rates between the poor and nonpoor results from infectious diseases. For example, TB is almost exclusively a disease of the poor, partly due to crowding and the lack of effective treatment of active cases. Disease control efforts directed at TB, malaria, and diarrhea will have disproportionate benefits for the poor because they bear a larger burden of disease.

Increasing the resources available for health centers and health posts. Public subsidies for health centers and health posts are much more equitably captured than those for hospitals. Hence, increasing the resources available for these facilities will also have a disproportionate effect on the poor. Increasing the availability of supplies, improving quality of care, and improving the working condi-tions of health workers in these facilities will be efficient means for improving the health of the poor.

Measuring use of services by the poor. An important means for improving the health of the poor is to regularly measure the extent to which they are benefiting from health services. Until now, health statistics have rarely been disaggregated by income level or other indicators of dep-rivation. Data routinely collected at health facilities are difficult to break down by income; however, this is possible to achieve during household surveys. If DMCs routinely track disaggregated coverage data as part of their management information systems, discrepancies between the poor and the better-off can be recognized and alleviated.

Employing participatory approaches. Employing participatory methods at the field level, such as the formation of village health committees and establishment of a system of community health volunteers, may help improve the responsiveness of the health care system to the needs of its clients, particularly the poor. Unfortunately, implementing these participatory approaches on a large-scale has proven difficult, although NGOs have enjoyed success in smaller-scale programs.

Targeting health services. Targeting health services is an attempt to increase the efficiency of the system by withholding subsidies from the nonpoor in favor of the poorest sectors of the society. However, there is little reason to believe that targeting, by itself, will increase access. There are a number of other difficulties with targeting. First, the extent to which ill health and poverty cluster in distinct geographical locations or among identifiable groups is limited. Data from Indonesia indicates that targeting the poorest 30 percent of villages will reach only 56 percent of the poor. Excessive targeting might, therefore, miss a large proportion of the poor. Second, there are programmatic and managerial costs associated with target-ing that may be substantial. Third, the data used for targeting may not be accurate, resulting in misclassification. Where the data for targeting must be collected, this may entail a significant cost. Self-targeting through a focus on the health problems of the poor and facilities more frequently used by them is usually a better and less costly approach.

Improving women’s health

There are a number of specific actions that DMC governments can undertake in the health sector to improve women’s health. First, they can ensure women have access to a package of basic services that include (i) family planning with a wide selection of contraceptive methods; (ii) tetanus toxoid immunization; (iii) supplementation with vitamin A, iron, folate, iodine, and where appropriate, protein; (iv) intensive efforts to control reproductive tract infections; (v) systematic treatment of TB (more women of reproductive age die each year of TB than of maternal causes); and (vi) good quality maternal health services. Second, DMC governments can improve women’s access to these health services in a number of ways. Physical access can be improved by reducing the time women must travel to obtain services, either through improved outreach services or establishment of additional health centers and health posts. Financial access can be improved by waiving or reducing user charges for women. (This would be easy to implement, but has rarely been tried.) “Cultural” access to services can be improved by increasing privacy in health facilities, recruiting and deploying more female health workers, and specifically targeting greater health education efforts at women. For example, Indonesia and Malaysia have begun counseling adolescent women about family planning and other aspects of repro-ductive health. Third, DMC governments can ensure that the health care system, com-munities, and women themselves, are more gender sensitive. It is important to train health workers and policymakers in the special needs of women and alert them to their special role in helping improve the status of women. This should include training on recognizing and dealing with violence against women. In addition, health statistics should be routinely disaggregated by gender, where appropriate, so that gender disparities can be identified and addressed.

Increasing emphasis on the health of indigenous peoples

Improving the health status of indigenous peoples will first require a better understanding of their current health status and health needs. In this regard, applied sociological and anthropological studies will be important in understanding their views about health and how to sensitively respond to their felt needs. Based on currently available information, efforts to improve the health of indigenous peoples should focus on (i) establishing more health centers and health posts in areas populated by indigenous peoples to improve physical access; (ii) increasing financial access by reducing or waiving charges; (iii) identifying, training, and recruiting ethnic minority health workers who can provide services in their communities; (iv) encouraging the use of beneficial traditional practices alongside modern health services; and (v) community-based approaches that include traditional leaders.

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