Health and Poverty

1. Health and Poverty Dr. Fikriye YILMAZ Department of HealthCareManagement Faculty of HealthSciences Baskent University

2. Remarkableprogress in economicdevelopmentandwell-beinghas beenaccomplished in developingcountriesoverthepasthalfcentury. • But povertycontinuesto be pervasive, difficulttodealwith – andindefensible.

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

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

6. What is poverty? Poverty is perceived in various ways

7. Definition of Poverty • In general, itis the inability of people to meet economic, social and other standards of well-being. • Unacceptablehuman deprivation in terms of economicopportunity, education, health and nutrition, as well as lack of empowerment and security.

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

9. 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

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

11. Objective vs. Subjective Poverty • 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. • 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.

12. Human Poverty Deprivation of essentialcapabilitiessuch as a longandhealthy life, knowledge, economicresourcesandcommunityparticipation.

13. The Feminisation of Poverty • In most countries poverty has a female face: about 70 percent of the 1.2 billionpeople living in poverty are female. • In many countries, the number of women inpoverty has risen significantly over that of men over the last two decades. • Womenare twice as likely as men to be illiterate andsignificantly more likely to suffer from povertyrelatedhealth conditions such as iron deficiencyanaemiaand protein-energymalnutrition.

14. The Elderly: A Traditionally Vulnerable Population • Maintaining a viable income in the later years of life is an issue with which manystruggle. • 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 inAsia are still in the workforce, employed mostly in agriculture.

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

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

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

18. UNDP Measures of Poverty

19. 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.

20. 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.

21. 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.

22. 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.

23. 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

24. Social Protection in Turkey • Old Age and Disability assistance formulated under Law 2022 • Social Services and Children ProtectionOrganization • GreenCardProgramme • Social Assistance and Solidarity Encouragement Fund and its affiliated 931 Social Assistance and Solidarity Foundations • Social Risk Mitigation Project • ConditionalCashTransfers

25. POVERTY AND HEALTH Poverty and ill-health: the vicious circle Characteristics of the poor Inadequate service utilization, unhealthy sanitary, dietary practice, etc. Poor health outcomes Ill health Malnutrition High fertility Diminished income Loss of wages Costs of health care Greater vulnerability to catastrophic illness 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

26. Most of the illnesses associated with poverty areinfectious diseases, such as diarrhoeal illness, malaria, and tuberculosis. • All of them are associated with the lack ofincome, clean water and sanitation, food, andaccess to medical services and education withcharacterise poor countries and communities. • The diseases are linked to undernutrition andchildren are most susceptible to them . • The environmental, social, and dietary changesproduced by industrialisation and urbanisationare leading to higher rates of diabetes,hypertension, heart disease, and respiratoryillness among both the urban poor and not so poor.

27. 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.

28. In addition, poor people are also more vulnerableto environmental threats to health, such aspolluted air and water, which undermine thequality of theirlives. • Preventable and treatable diseases therefore takean enormous toll on the poorest people. • Primarily in developing countries, people diefromeightvaccine-preventablediseases. • An estimated 1.7 million people in developingcountries die annually from diseases linked tounsafe water and sanitation and poor hygiene.

29. The vicious cycle of ill health has a greaterimpact where poor people are generally notcovered by adequate health insurance the covered thatprotects their access to health services.

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

31. 150 million people suffer catastrophic health care costs each year

32. Catastrophic Health Expenditure And ImpoverishmentDue To Out-of-pocket Health Expenditure, By Who Region

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

34. The Relationship Between Catastrophic Expenditure And Out-of-pocketPayments For Health Care

35. 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

36. Policy impact • Expand insurance coverage with sufficient benefitpackage • Pragmatic and sustainable risk pooling mechanismneeded • Remove physical and financial barriers to accesshealthservicesforpoor • The improvement of physical access to healthservices must be accompanied by financialprotectionpolicy • Socio-economiccharacteristics of households provide evidence for policy focus

37. 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

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

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

40. Purposes of the Study • Toanalyze the “poverty” phenomenain the basis of health status and health expenditures • Todetermine 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.

41. Tools of the Study • A questionnaire form • Household Living Standards Surveys • Household Income and Expenditure Surveys • Household Budget Surveys • SPSS 12.0 softwareprogramme • Hypothesis were tested by using chi-square, t-tests and Mann- Whitney U tests.

42. KEY FINDINGS

43. Household Catastrophic Health Expenditures • Acceptedthat 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.

44. The rates of households face catastrophic health expenditures as to different thresholds

45. 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.

46. 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.

47. 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 suddenillness or injury such as flu, diarrhea, and a fracture last 4 weeks.

48. 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

49. Recommendations • Policy • There is a need for a set of principles to guide policy making and program developmentin relation to poverty and health. • The social issues of poverty should be connected to health issues for an integratedpublicpolicyapproach. • Income related health outcomes and gradients of inequality in health status represent apotentialstoryline.

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