Beneath the Surface
Poverty - Health - Alleviation
The pervasiveness of poverty in Bangladesh is well documented. The latest nation-wide statistics on poverty released by the Bangladesh Bureau of Statistics (BBS) leaves no room for complacency. The Poverty Monitoring System of the BBS (printed in Monitoring Adjustment and Poverty (MAP) newsletter of CIRDAP, December 1997) postulates that in April 1996, 48 per cent of the rural and 44 per cent of the urban population continued to lie below the poverty line with a per capita per day calorie intake of 2122 k.cal in rural areas and 2112 k. cal in urban areas. According to the survey undertaken by the said source, the monthly income of the urban household stood at Tk 1,507 (about $34) and that of rural at Tk 673 ($15). The aggregate statistics, however, conceals more than it reveals. For example, the per capita income of the urban poor is one-fifth of the average income of the urban non-poor. On the other hand, the average per capita income of the rural poor is 42 per cent of the rural non-poor. The Gini-coefficient - that captures income inequality - is reported to be 20 per cent higher in urban areas compared to rural areas. Statistics on income shares of the lowest and the top deciles appear to substantiate the hypothesis: the lowest decile in urban areas constitutes 8 per cent of the population but reaps one per cent of the income share. For rural areas, the figures are 13 per cent and 54 per cent respectively.
Readers should be aware of the fact that expenditure pattern by decile groups could posit lower income inequality in both rural and urban areas "due to the fact that households of lower income groups improve their consumption through access to ecological/community resources."
Of all the poverty reducing instruments orchestrated by Bangladesh government - promoting income growth of the poor, interventions in education, nutrition and health - public expenditure on health can meaningfully influence poverty alleviation. "Public expenditures on health provide opportunities for the poor to improve their health status and other capabilities to earn higher incomes and enhance living standards." There is, in evidence, a rise of total public expenditure on social sectors (e.g. health, education and family planning) from around 15 per cent in the early 1980s to over 22 per cent in the 1990s. "In absolute terms, the expenditure on health has been increasing. For instance, in constant 1972/73 prices, per capita public expenditure on health and family planning increased from Tk. 6.67 in 1983/84 to Tk 12.33 in 1993/94". Disconcertingly, the share of expenditure on primary health care in total health spending has declined from 39 per cent in 1990/91 to 33 per cent in 1993/94 - as opposed to a rise in secondary health care from 34 per cent to 42 per cent.
The moot question is: Has the rise in per capita health expenditure - springing from increased budgetary allocations of the government - reached the poor to positively affect their poverty?
MAP research findings provide an "incidence analysis" of health expenditures in 1994 suggesting how "gross" benefits of government health spending are distributed across various income groups. Let us pick up a few shots from their estimates:
Bottom 20 per cent of the households are reported to reap home nearly 22 per cent of public spending on rural health while top 20 per cent bag 21 per cent. Accounting for 52 per cent of households in 1994, the poor claimed 57 per cent of public spending on health; the share of non-poor is 43 per cent. "Thus the pattern of public health expenditure is not so skewed. Households of the top income decile receive 14 per cent compared to 13 per cent of the lowest income decile. The emerging pattern is pro-poor." More revealing, the poorest income decile - sharing only 2 per cent of rural income - is observed to have pocketed 13 per cent of total health benefits.
MAP report also points out the disturbing aspect of public health intervention in rural areas: (a) the share of public health access is still limited to only 12-13 per cent with negligible variation across income groups; (b) the access to maternal health care is dismally low at 1 per cent; (c) the share of rural health expenditures on curative care has declined over time; (d) poor quality of health services is reflected by opinion received from beneficiaries: 28 per cent cite that doctors pay inadequate attention, another 26 per cent cite non-availability of medicines as the principal cause for not availing public medical services.
By and large, the distribution of public health spending over various income groups is more egalitarian than other forms of interventions in poverty alleviation. "Since poverty is a complex process of multi-dimensional nature, the key to sustained reduction in poverty requires not just resources but combining resources with local social mobilization, capacity building and creating enabling conditions for empowering the poor."
Poverty is both a cause and effect of health status pertaining to the poor. The facilities should be extended to the poor at a low price so that the increased human capability could outweigh the costs incurred. And government should make sure that things are right on health front.
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