Health and Poverty Dr Fikriye YILMAZ Department of

Health and Poverty Dr. Fikriye YILMAZ Department of Health Care Management Faculty of Health Sciences Baskent University

• Remarkable progress in economic development and well-being has been accomplished in developing countries over the past half century. • But poverty continues to be pervasive, difficult to deal with – and indefensible.

• Strong economic growth, better access to essential public services and reduced inequalities – in particular as regards gender – are key factors for reducing poverty.

• As are sustained, adequately resourced and co -ordinated actions across government policies and development co-operation activities.

What is poverty? Poverty is perceived in various ways

Definition of Poverty 1. In general, it is the inability of people to meet economic, social and other standards of well-being. 2. Unacceptable human deprivation in terms of economic opportunity, education, health and nutrition, as well as lack of empowerment and security. 7

Interactive dimensions of poverty and well-being PROTECTIVE Security Vulnerability ECONOMICS Consumption Income Assets GENDER POLITICAL Rights Influence Feedom ENVIRONMENT HUMAN Health Education Nutrition SOCIOCULTURAL Status Diginity

Different Kinds of Poverty Relative vs. Absolute Objective vs. Subjective Urban vs. Rural Internal (personal) vs. External (systemic) Causes • Short-term vs. Long-term • Clustered (wide-spread) vs. Isolated • Human Poverty • • 9

Absolute vs. Relative Poverty Absolute • Actual deficits • Primarily physical consequences Relative • Comparative • Perceived deficits • Primarily emotional consequences 10

Objective vs. Subjective Poverty • The percentage of people whose income is below a poverty line. • The critical threshold of income, consumption or more generally access to goods and services below which individuals can not fulfill basic needs. • Asking people to report whether their income is sufficient; what level of income would be adequate to make ends meet or to identify themselves as poor.

Human Poverty Deprivation of essential capabilities such as a long and healthy life, knowledge, economic resources and community participation. 12

The Feminisation of Poverty • In most countries poverty has a female face: about 70 percent of the 1. 2 billion people living in poverty are female. • In many countries, the number of women in poverty has risen significantly over that of men over the last two decades. • Women are twice as likely as men to be illiterate and significantly more likely to suffer from poverty related health conditions such as iron deficiency anaemia and proteinenergy malnutrition.

The Elderly: A Traditionally Vulnerable Population • Maintaining a viable income in the later years of life is an issue with which many struggle. • In many developing countries, retirement is a luxury that few can afford. • Approximately 40 percent of individuals over 64 years in Africa and 25 percent in Asia are still in the workforce, employed mostly in agriculture.

How can poverty be measured and monitored? • Poverty can be measured by different purposes – specific poverty action – general poverty comparisons – setting goals and benchmarks

Measuring poverty at different aggregation levels CONSUMPTION Single indicator Composite indexes ECONOMIC Discrete indicators HUMAN DEVELOPMENT INDEX HUMAN POVERTY INDEX GENDER-RELATED DEVELOPMENT INDEX HUMAN SOCIOCULTURAL POLITICAL PROTECTIVE

Measures of Poverty • • • Headcount Index Poverty Gap Index Poverty Severity Index The Sen-Shorrocks-Thon Index The Watts Index Time Taken To Exit

UNDP Measures of Poverty Measure Components Human Development Index Life expectancy at birth, adult literacy, educational enrollment, GDP per capita Gender-related Development Index As above, adjusted for gender differences Gender Empowerment Measure Seats in parliament held by women, female administrators and managers, female professional and technical workers, women’s shareof earned income Human Poverty Index (developing countries) People not expected to survive to 40, illiteracy, access to safe water, access to health services, underweight children Human Poverty Index (developed countries) People not expected to survive to 60, functional illiteracy, people below mean income, long term unemployment

Poverty with Numbers in the World • 1300 million people of the world’s population live on less than one dollar a day. • 2800 million World people struggle to survive on less than two dollars per day. • The average income in the richest 20 countries is 37 times the average in the poorest 20—a gap that has doubled in the past 40 years.

• Every year eleven million children die —most under the age of five and more than six million from completely preventable causes like malaria, diarrhea and pneumonia. • In rich countries less than 1 child in 100 does not reach its fifth birthday, while in the poorest countries as many as a fifth of children do not. • And while in rich countries fewer than 5 percent of all children under five are malnourished, in poor countries as many as 50 percent are.

Hunger • More than 800 million people go to bed hungry every day. 300 million are children. • Of these 300 million children, only eight percent are victims of famine or other emergency situations. • More than 90 percent are suffering long-term malnourishment and micronutrient deficiency. • Every 3. 6 seconds another person dies of starvation and the large majority is children under the age of 5.

Water • More than 2. 6 billion people —over 40 per cent of the world’s population—do not have basic sanitation, and more than one billion people still use unsafe sources of drinking water. • Four out of every ten people in the world don’t have access even to a simple latrine. • Five million people, mostly children, die each year from water-borne diseases.

Poverty in Turkey – The probability at birth of not surviving to age 40; % 8. 0 – Adult illiteracy rate (% ages 15 and above); %13. 5 – Population without sustainable access to an improved water source; % 18 – Children under weight for age (%under age 5) ; % 8 – Population below income poverty line • $ 1 a day (absolute poverty); % 2. 7 • $ 2 a day (poverty line); %10. 3

Social Protection in Turkey • Old Age and Disability assistance formulated under Law 2022 • Social Services and Children Protection Organization • Green Card Programme • Social Assistance and Solidarity Encouragement Fund and its affiliated 931 Social Assistance and Solidarity Foundations • Social Risk Mitigation Project • Conditional Cash Transfers

POVERTY AND HEALTH Poverty and ill-health: the vicious circle Characteristics of the poor Inadequate service utilization, unhealthy sanitary, dietary practice, etc. Caused by; Lack of income&knowledge, Poverty in community-social norms, weak institutions and infrastructure, bad environment; Poor health provision-inaccessible, lack of key inputs, irrellevant services, low quality; Excluded from health finance system -limited insurance, co-payments Poor health outcomes Diminished income Ill health Malnutrition High fertility Loss of wages Costs of health care Greater vulnerability to catastrophic illness

• Most of the illnesses associated with poverty are infectious diseases, such as diarrhoeal illness, malaria, and tuberculosis. • All of them are associated with the lack of income, clean water and sanitation, food, and access to medical services and education with characterise poor countries and communities. • The diseases are linked to undernutrition and children are most susceptible to them. • The environmental, social, and dietary changes produced by industrialisation and urbanisation are leading to higher rates of diabetes, hypertension, heart disease, and respiratory illness among both the urban poor and not so poor.

• Poor countries and poor people suffer from multiple deprivations that translate into high levels of ill health and disability. • Poverty is an absolute barrier to good health. It impacts health by influencing all other factors adversely. • The poor are more vulnerable to disease owing to, their lack of access to promotive, preventive and curative health care, nutritious food and financial resources.

• In addition, poor people are also more vulnerable to environmental threats to health, such as polluted air and water, which undermine the quality of their lives. • Preventable and treatable diseases therefore take an enormous toll on the poorest people. • Primarily in developing countries, people die from eight vaccine-preventable diseases. • An estimated 1. 7 million people in developing countries die annually from diseases linked to unsafe water and sanitation and poor hygiene.

• The vicious cycle of ill health has a greater impact where poor people are generally not covered by adequate health insurance the covered that protects their access to health services.

Catastrophic Health Expenditure • Out-of-pocket health expenditures is equal to or more than 40% of household nonsubsistence spending • Reduce other basic expenses • Push some households into poverty • Forgo health services and suffer illness

150 million people suffer catastrophic health care costs each year

Catastrophic Health Expenditure And Impoverishment Due To Out-of-pocket Health Expenditure, By Who Region

Out-of-pocket payments are the main cause of catastrophic spending

The Relationship Between Catastrophic Expenditure And Out-of-pocket Payments For Health Care

Results from Cross Country Analysis • Higher percentage of households with catastrophic expenditure is associated with: – higher share of OOP in total health expenditure – higher percentage of population under poverty line – higher percentage of total health expenditure share of GDP

Policy impact • Expand insurance coverage with sufficient benefit package • Pragmatic and sustainable risk pooling mechanism needed • Remove physical and financial barriers to access health services for poor • The improvement of physical access to health services must be accompanied by financial protection policy • Socio-economic characteristics of households provide evidence for policy focus

The economic rationale for investing in the health of the poor • Higher labour productivity • Higher rates of domestic and foreign investment • Improved human capital • Higher rates of national savings • Demographic changes

Key Policy Areas for Pro-poor Health The main determinants of health

A Field Study Of Determination Of Health Services Utilization And Catastrophic Health Expenditures Of Poor Households in ANKARA (TURKEY)

Purposes of the Study • To analyze the “poverty” phenomena in the basis of health status and health expenditures • To determine the reasons and results of catastrophic health expenditures of households deemed as poor • The study covers 92 households determined as priority group for assistances by Etimesgut Social Solidarity Foundation in Ankara.

Tools of the Study • A questionnaire form – Household Living Standards Surveys – Household Income and Expenditure Surveys – Household Budget Surveys • SPSS 12. 0 software programme • Hypothesis were tested by using chi-square, ttests and Mann- Whitney U tests.

KEY FINDINGS

Household Catastrophic Health Expenditures • Accepted that health expenditures are catastrophic if it is ≥ 40 % of the non-food expenditures (capacity to pay), some characteristics of households facing catastrophic health expenditures are exposed.

The rates of households face catastrophic health expenditures as to different thresholds Households facing Catastrophic health expenditures as to the Out-of-pocket share of health expenditure in health total expenditure non-food expenditure spending Number Percentage (%) (n) 5% 51 55, 4 58 63 10 % 40 43, 5 43 46, 7 15 % 32 34, 8 36 39, 1 20 % 28 30, 4 31 33, 7 25 % 21 22, 8 27 29, 3 30 % 16 17, 4 21 22, 8 40 % 11 12 14 15, 2 50 % 10 10, 9 60 % 4 4, 3 9 9, 8

Characteristics of 14 households facing catastrophic health expenditure; – There is only one household head with secondary education. 50 percent of household heads are completed primary school. 14. 3 percent are literacy, but no completed primary school. And 28. 6 percent of household heads are illiteracy. – While 64. 3 percent of households live in a slum, 35. 7 percent live in an apartment house.

– Overall one in two households is renters. Renter households pay rental fees averagely 142, 85 YTL. 2 of renter households receive aid from a relative. – Only 14. 3 percent of household heads work for wages. Reasons of not working for wages of other people are generally retired/ too old to work (% 75), ill health (% 25). – Overall one in two household heads is in the coverage of any compulsory health insurance system. Of these people, 57. 1 percent is beneficiaries of Green Card, 42. 9 percent of SSO. Among household members, three in four is in the coverage of Green Card; another is in the coverage of SSO.

– Members of three of 14 households live on less than 2. 15 $ per day. All household members struggle to survive on less than 4. 3 $ per day. – Total 28 household members (% 49. 1) living in these households have at least one chronic illness/ disability that has lasted more than 6 months. The most common chronic illnesses are hypertension and diabetes mellitus. – 11 household members have had any sudden illness or injury such as flu, diarrhea, and a fracture last 4 weeks.

Poor people have worse health Ill health is a dimension of poverty Ill health generates poverty Income is a determinant of health Health service utilization depends on user fees and insurance coverage • Health facilities serving the poor are inadequate • Improving the health of the poor • • •

Recommendations • Policy – There is a need for a set of principles to guide policy making and program development in relation to poverty and health. – The social issues of poverty should be connected to health issues for an integrated public policy approach. – Income related health outcomes and gradients of inequality in health status represent a potential storyline.

• Policy – “Policy entrepreneurs” who are knowledgeable about the issues and who can get them on the public agenda need to be mobilized and supported. – Inter-sectoral structures need to be established to orient and coordinate policies and programs in separate policy areas towards a common objective.

• Policy – A societal outcome/well-being approach may help policy makers address poverty and health by focusing on activities across sectors that contribute to the overall goal of raising health status. – Policy makers should be offered substantive advice on the optimal mix of up-stream and down-stream interventions and an integrative intervention framework. – In the short term, a strategy is needed to make the more aware of the link between poverty and health.

• Research – Long-term strategies are needed to cross some of the barriers. – A long-term research program is needed to assess policy interventions of all kinds. – Formal strategies should be developed to encourage researchers to talk to people living in poverty, bringing their experience into the mainstream of research and policy making. – More research is needed on the link between poverty and health at the population level and the pathways between poor health status and low socioeconomic status. – Also needed are longitudinal studies that examine the life course impacts that poverty and income inequality have on health.

BIBLIOGRAPHY • • • Abul Naga and Lamiraud (2008). Catastrophic Health Expenditure and Household Well-Being. Working Paper. Institute of Health Economics and Management. Baharoglu and Kessides (2002). Macroecomoic and Sectoral Approaches. “Chapter 16: Urban Poverty”: 125 -126. DFID (2000). “Better Health For Poor People”. INTERNATIONAL COUNCIL OF NURSES (2004) “Nurses: Working With The Poor; Against Poverty”. Information And Action Tool Kit OECD (2001). “Poverty Reduction”. The DAC Guidelines. (www. oecd. org/poverty) OECD (2001). “Human Health and the Environment”. OECD Environmental Outlook. Ch. 21: 249 -255. OECD (2003). “Poverty and Health in Developing Countries: Key Actions”. OECD and WHO (2003) “Poverty and Health”. DAC Guidelines and Reference Series. France. Wagstaff (2002). “Poverty and Health Sector Inequalities”. Bulletin of the World Health Organization(80): 98. WHO (2008 -2009) “World Health Statistics”. XU, Ke and et. al. (2003) “Household Catastrophic Health Expenditure: A Multicountry Analysis. ” Lancet (362): 111 -17

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