Getting the Poor Their Due

In many developing countries, less than 20 percent of the benefits of public health programs reach the poorest 20 percent of the population. Even high-priority services aimed specifically at the underserved, such as free child immunizations, are often "captured" first by those in more comfortable economic circumstances.

"We tend not to think that better-off people are in competition with the poor for public health care programs, but they are," says Hugh Waters, assistant professor of International Health.

This puzzling situation may be changing—in part because Waters, PhD '98, MS, and David Peters, an associate professor of International Health, are working with the Reaching the Poor Program (RPP), created in 2001 and funded by the World Bank and the Bill & Melinda Gates Foundation.

From 2001 to 2004, RPP scientists pilot-tested 11 different health-delivery strategies in an array of developing countries. The 11 projects were run by different kinds of organizations—government agencies, NGOs, for-profit entities—so the researchers could find out which health, nutrition and population programs reached the poor most widely within the different settings.

There were some striking successes: In Ghana, when the government and the Red Cross linked their distribution of insecticide-treated bed nets with ongoing mass immunization campaigns, they found that bed net ownership by the poorest 20 percent of the population rose from less than 5 percent to more than 90 percent.

And there were failures: In a Bangladesh program meant to boost the numbers of attended deliveries among the population as a whole, 3 to 3.5 times more better-off women received attended deliveries than did the poorest clients. "A lot of things were assumed to be pro-poor but in fact, when we examined them, the evidence was not there," says Peters, MD, DrPH '93, MPH '89.

The Reaching the Poor Program has now published a book, Reaching the Poor, about the 11 experiments. The authors stress that none of the winning strategies will solve every health crisis everywhere. "Don't assume," says Waters, "just because your intentions are good, that your program is reaching the poor. And since none of RPP's successful programs was a magic bullet, health officials must draw on what has worked elsewhere and then adapt those strategies to local conditions."