The impact of poverty on health in Nepal
Suvash Shrestha discusses how the causal relationship between poor health and poverty runs in both directions
About 1 billion people globally live in extreme poverty on an income of less than $1 a day, of whom 70 million live in Asia and the Pacific (1). These regions are also struggling hard to provide health facilities and services and there are high rates of mortality from conditions which could easily be prevented or treated. It is not hard to see the strong correlation between economic and health status. And since poverty breeds poor health which keeps people poor, it is a very serious and emergency condition that should receive global attention.
Both at the individual and national levels, poverty is no doubt the biggest hurdle we have to overcome to achieve satisfactory health status. There are stark disparities in health expenditure between rich and poor countries. In Nepal, the per capita total expenditure on health in 2004 was less than 0.2 % of per capita expenditure in the USA (2).
At the individual level
At the individual level poor people have a difficult time living hand to mouth. They have to work in adverse conditions like brick kilns and factories without any protective measures, exposing them to occupational health hazards. To add more insult, poor people can rarely afford adequate nutrition leading to undernourishment which increases their vulnerability to disease. Owing to poverty, people can not afford to maintain proper sanitation and hygiene which again predispose them to various diseases.
In addition, limited access to education leaves the poor completely oblivious of the disease conditions, their prevention and treatment. They still live with many superstitions and myths which may result in harmful health practices. Many cannot afford the luxury of TV and radios, and in Nepal where the adult literacy rate is only 48.6% (2), most poor people cannot read newspapers and magazines. This restricts access to information about health which is disseminated via the media.
Due to extreme work pressure and the need to earn few more rupees to support their family, poor people rarely have time to attend health promotion programs in their community such as training on sanitation, proper nutrition, family planning, vaccination and free health camps. Annually, the government of Nepal has been running free programs like pulse polio immunization program and vitamin A capsule distribution. But the poor, having to work from dawn to dusk, don’t get time to get their children vaccinated. So, from every way, they miss the health information and they have no idea what facilities are available for them even if there are any.
What is more, even when they fall sick, the poor have many barriers to accessing health care. The biggest of all is the financial one. The treatment services are often too expensive for them, and at centers where services are free, limited funding can mean that the range of services offered is very low. In some areas, there are fee waiver and exemption schemes to help the poor but in practice these have been found to benefit better off groups rather than the most needy. Because health services are centered in the urban areas, they have to travel a long distance to access health services, and even the cost of transport can form a major barrier.. The time spent seeking medical care also means a loss of income,a further deterrent from doing so. Thus, service availability, accessibility, prices and quality greatly affect health outcomes for the poor.
An associated problem is that the poor may not care for minor ailments. Due to a lack of knowledge and poor access to health services, they may not to get a check up until the symptoms become severe, usually at advanced stages of disease.. This makes treatment difficult, more costly and longer. Low incomes are also associated with reduced compliance with treatment regimes, since patients who have begun to recover may chose to spend money on other family needs rather than on costly medicines. thus never receiving complete treatment. This is especially true for diseases like tuberculosis. Here the problem was so grave that even when the Nepalese government provided anti-tubercular drugs for free, the poor would collect the drugs from the hospital and sell them to local pharmacists at a lower price to earn some money for their family. Thanks to the Directly Observed Treatment Short courses (DOTS), compliance with treatment has improved, but the constraints of poverty have not changed.
At the national level
At the national level, government has not been able to assure health facilities to all. If we look at the national budget distribution in Nepal, the health sector received only 9.23% of total allocations this year, as little as US $191 milion. (3) The figure clearly depicts how serious the condition is.
In poor countries, the number as well as the quality of health centers is unsatisfactory. Nepal has only 0.21 doctors per 1000 people and only 2 hospital beds per 10,000 people compared to 2.56 doctors per 1000 people and 33 beds per 10,000 people in the USA (2). Even these figures do not capture the gravity of the situation in the rural areas, since most hospitals and health services are centered in the urban centres. In remote areas, where most of the neediest live, there are only some health posts and sub-health posts which are also not sufficient and are barely equipped.
Even the so-called big centres are very ill-equipped without even an X-ray and or a US machine, let along CT and MRI scanners. In places where this equipment is available; it often remains out of working order due to poor maintenance, or unused due to a lack of trained staff. Staffing is another big problem; in Nepal, only 20% of rural physician posts are filled in comparison with 96% in urban areas (1). This is most likely because the government has failed to provide adequate salaries and other facilities. This is also the reason why most health professionals are flying away to the developed countries in search of better incomes and a better quality of life.
On account of poverty, government has failed to promote any research in the field of health. New discoveries are far-fetched things, and even the basic study of health status and disease prevalence are lagging due to very little funding. There are no proper training programs for health workers. Government has not been able to launch regular health campaigns and screening programs, and those which have been initiated are yet to reach all corners of the country. Even the donor agencies struggle to reach the needy ones due to poor transportation facilities.
The search for solutions
The definite solution lies in finding new resources and using the available ones to the maximum. Realizing that resources are always limited, we should be able to make the most out of them. The first step should be to prioritize our needs. For this proper studies should be done at the grassroots level to ensure that plans formulated are appropriate for national social, cultural and economic status.
Resources should be reallocated in favor of poorer geographic areas, and to the lower tiers of service delivery. Investments should be focused in health conditions that disproportionately affect the poor like TB, malaria, HIV, infant and child mortality, maternal ill health and malnutrition.
Curative treatment is expensive, so we should focus on the preventive aspects. We can educate village health workers about proper hygiene and sanitary practices, nutrition, the importance of vaccination, family planning and other relevant topics. Since they are from the community itself, they could deliver this information directly to our target groups and could thus be very effective.
Large health centers are too expensive to establish and maintain, as they require more manpower, resources and equipment. Instead we could run community based small health centers which would be cost-effective and easier to set up in remote areas. Regular mobile health camps could also be a very effective solution.
Since many developed countries are willing to help, the government should welcome them and provide a politically stable environment in which to work.
Conclusion
The causal relationship between poverty and health runs in both directions; poverty breeds ill health and ill health keeps people poor. It is therefore vital to break this vicious cycle for a healthy population and a prosperous nation. After all, a healthy population is more economically productive than one that is not, allowing goals in other sectors to be achieved faster.
Suvash Shrestha
Kathmandu Medical College
Kathmandu
Nepal
suvashsht@gmail.com
(1) WHO, Fact sheets, Health, poverty and MDG, accessed October 25 2007, http://www.wpro.who.int/media_centre/fact_sheets/fs_20050621.html
(2) WHO, Core health indicators; accessed October 25, 2007, http://www.who.int/whosis/database/core/core_select_process.cf
(3) National Budget, accessed October 25 2007, available from http://www.mof.gov.np/publication/speech/2007/pdf/BudgetSpeech_english.pdf
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