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World Bank conference debates how to reach the poor
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     BMJ

    Health services designed to favour the poor do not necessarily reach the most needy in societies. That was the conclusion of a group of World Bank policy makers and programme officers working in developing and transitional countries who met last week in Washington, DC, to discuss better ways to reach the most vulnerable people.

    Described as "taking stock" of how well the bank's programmes are reaching the poor, the conference reflected growing awareness in the international development community that "health systems are unconsciously regressive and tend to bias against the poor and most needy."

    In his opening address, Davidson Gwatkin, principal health and poverty specialist at the World Bank and organiser of the conference, said the focus must be on not just the presence or absence of health and nutrition services but also on their distribution. Programmes aimed at preventing or alleviating HIV infection, tuberculosis, and malaria, for example, are often assumed to reach the poor merely because these are seen as diseases of the poor, but that assumption is increasingly questioned, he said.

    Delegates at the conference, which was funded by the Bill and Melinda Gates Foundation and the Swedish and Dutch governments, learned that many health, nutrition, and population services, because they favour the better off, themselves contribute to disparities in health status. Such disparities are found not only in routine health services but often also in programmes run especially to benefit the poor.

    In a series of case study presentations commissioned by the bank—one third of them from the developing world—Joel Selanikio of the American Red Cross described a collaborative project in which the distribution of insecticide treated bed nets was "piggy backed" to measles campaigns in Ghana and Zambia. He said this resulted in over 90% coverage. Researchers from the University of Cape Town and the London School of Hygiene and Tropical Medicine described how the multidisciplinary nature of two large scale voluntary counselling and treatment programmes for HIV/AIDS in South Africa contributed to comprehensive coverage among disadvantaged socioeconomic and ethnic groups.

    But these successes were said to have been achieved in the face of severe challenges to adequately reaching the poor, such as the lack of infrastructure and efficient health systems.(Jocalyn Clark)