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Can Social Inclusion Policies Reduce Health Inequalities in Sub-Saharan Africa?—A Rapid Policy Appraisal
Abstract and Figures
The global resurgence of interest in the social determinants of health provides an opportunity for determined action on unacceptable and unjust health inequalities that exist within and between countries. This paper reviews three categories of social inclusion policies: cash-transfers; free social services; and specific institutional arrangements for programme integration in six selected countries--Botswana, Mozambique, South Africa, Ethiopia, Nigeria, and Zimbabwe. The policies were appraised as part of the Social Exclusion Knowledge Network (SEKN) set up under the auspices of the World Health Organization's Commission on Social Determinants of Health. The paper highlights the development landscape in sub-Saharan Africa and presents available indicators of the scale of inequity in the six countries. A summary of the policies appraised is presented, including whether or what the impact of these policies has been on health inequalities. Cross-cutting benefits include poverty alleviation, notably among vulnerable children and youths, improved economic opportunities for disadvantaged households, reduction in access barriers to social services, and improved nutrition intake. The impact of these benefits, and hence the policies, on health status can only be inferred. Among the policies reviewed, weaknesses or constraints were in design and implementation. The policy design weaknesses include targeting criteria, their enforcement and latent costs, inadequate participation of the community and failure to take the cultural context into account. A major weakness of most policies was the lack of a monitoring and evaluation system, with clear indicators that incorporate system responsiveness. The policy implementation weaknesses include uneven regional implementation with rural areas worst affected; inadequate or poor administrative and implementation capacity; insufficient resources; problems of fraud and corruption; and lack of involvement of civil servants, exacerbating implementation capacity problems. The key messages to sub-Saharan African governments include: health inequalities must be measured; social policies must be carefully designed and effectively implemented addressing the constraints identified; monitoring and evaluation systems need improvement; and participation of the community needs to be encouraged through conducive and enabling environments. There is a need for a strong movement by civil society to address health inequalities and to hold governments accountable for improved health and reduced health inequalities.
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... Another significant social determinant is poverty. According to Rispel et al (2009), Poverty is a bigger killer than HIV, malaria and chronic diseases in Nigeria. And that the cyclical effect of poverty on health at the individual and population level makes it a major social factor that affects health outcomes. ...
... Abject poverty and squalor. Despite a number of poverty alleviation and economic empowerment programmes by government in Nigeria, a large percentage of the Nigerian population live on less than a dollar per day, this affects the conditions in which they live, what they eat and ultimately their health (Ndamu, 2017, Rispel et al 2009. The huge gap between the rich and the poor in Nigeria has been implicated as the major culprit for the poor health outcomes observed (Braveman 2002) The policies of the Nigerian government on addressing health inequalities are mostly unclear this is because the health system of the country itself is weak and mainly donordriven (Kehinde, n.d.) Cultural and religious values. ...
... Previous studies in South Africa found relatively insignificant differences in nutritional status between orphans and non-orphans [7]. Poor health status has been found to be associated with lower quality of life, decreased utilisation of health services by adolescents, and increased morbidity and mortality [7,38]. Overall, our findings and those of previous research works on school-going children's nutritional status suggest that the problem of malnutrition continues to affect school-going children in South Africa, with potential consequences for learning outcomes. ...
Background
The double burden of malnutrition among children remains a public health challenge in South Africa. In response, the government of South Africa developed the National Health Policy and Implementation Guidelines for school-going children in 2003. This policy was subsequently upgraded to ‘The Integrated School Health Programme’ in 2012. An element of the programme is the provision of a meal to school-going children on school days. However, evidence suggests that one-third of school-going children continue to have nutritional deficiencies. This study investigated the sociodemographic as well as the nutritional characteristics of school-going children participating in a school health initiative in KwaZulu-Natal Province, South Africa.
Methods
This was a retrospective descriptive cross-sectional study involving 1,275 children (50.3% females and 49.7% males) aged 3 to 15 years. Epidemiological data on the screening of the children’s nutritional characteristics by school health nurses and school health nutritionists under the integrated school health programme (ISHP) was reviewed and analysed for the study.
Results
Nearly half (50.3%) and 49.7% of the population were females and males, respectively. The average age of participants was 8.4 years old. ‘Underweight’ (p = 0.000), ‘overweight’ (p = 0.000), ‘at risk of overweight’ (p = 0.000),‘stunting’ (p = 0.000),‘severe stunting’ (p = 0.005), ‘wasting’ (p = 0.010), and ‘obesity’ (p = 0.037) were associated with the ‘schools that children attended’. School-going children’ living conditions were significantly associated with ‘normal weight’ (p = 0.000), ‘underweight’ (p = 0.000), and ‘underweight’ (p = 0.028). However, the social grant to parents/guardians had some positive effects on the percentage of children who reported ‘normal weight’ (55.4%), ‘wasting’ (1.0%), ‘underweight’ (4.0%), and ‘at risk of overweight’ (20.2%).
Conclusion
Chronic nutritional deficiencies persist among children. Therefore, ISHP implementation must retarget specific regions of the country to ensure that national goals and gains on school-going children nutrition, are met and maintained. Indeed, considering the positive impact of the government’s social grant programme on the nutritional status of the children in this study, we recommend policy reforms that will increase parents’ and carers’ access to means of subsistence in order to meet the health and nutritional needs of children in the study communities.
... Nigeria is a country with significant health inequities, as shown by health statistics [5]. There also exist widespread socio-structural barriers to fair access to essential health care services including high poverty and illiteracy levels coupled with geographical differences that can be attributed to predominant socio-cultural contexts [6]. ...
Background: Socioeconomic factors influence health outcomes and the distribution of health resources within and between countries globally. In Nige-ria, there are various socioeconomic factors that have been reported to be responsible for health inequities across the different geopolitical zones. Objective: To assess health inequities in relation to socioeconomic factors that affect access to essential health care services in Nigeria, using family planning, maternal care, and childcare as indicators. Method: The study involved a cross-sectional secondary analysis of data from the 2018 Nigeria Demographic and Health Survey (NDHS) and a literature review of transdiscipli-nary approaches to addressing health inequities. Result: The overall result from the findings suggests a strong influence of geographical and socioeconomic factors in the distribution of healthcare services. Specifically, family planning services were more readily available and accessible in the Southern zones of Nigeria than in the Northern zone of Nigeria, which could be attributed to socio-cultural, religious, and access-related barriers. Results also showed that access to most maternal and child health care services was often skewed towards the southern zones, which could be due to the presence of more healthcare workers who provide these services coupled with higher access to maternal care, hence a higher uptake and utilization of maternal care services. Also, children in the northern zones had lesser odds of receiving basic and age-appropriate vaccination than those in other regions, which could be attributed to the supply-side disparities that exist between the northern and southern regions. Conclusion: This study concludes that level of educational attainment, wealth quintiles, as well as financial barriers, are
... Néanmoins, des obstacles liés à l'environnement géographique et aux capacités des individus ont été relevés dans la plupart des situations étudiées. Ce point met en évidence les inégalités d'accès aux services de santé observées dans d'autres contextes en Afrique subsaharienne (Rispel et al., 2009 Ainsi, ces occasions manquées de dépistage lors de ces évènements sont d'autant plus dommageables qu'elles auraient pu contribuer à réduire la proportion importante de personnes en Côte d'Ivoire qui ignorent leur statut (Unaids, 2018b). ...
Avec 2,8 % de sa population adulte infectée, la Côte d’Ivoire est l’un des pays d’Afrique de l’Ouest les plus sévèrement touchés par l’épidémie à VIH. Son épidémie, dite mixte, est caractérisée par des prévalences élevées au sein des populations dites clés (Hommes ayant des rapports sexuels avec d’autres hommes — HSH — et travailleuses du sexe) et une prévalence moyenne en population générale. Cette spécificité de l’épidémie ivoirienne a conduit la plupart des bailleurs de fonds à changer de stratégie au cours des dernières années : le dépistage est réorienté vers les structures de santé et auprès des populations clés. Cependant, dans un pays où seules 54 % des personnes infectées connaissent leur statut, il est d’autant plus important d’évaluer si la stratégie de dépistage actuelle permet (i) un recours au dépistage large et répété chez les populations les plus exposées et (ii) le maintien d’un accès au dépistage en population générale. Le présent travail de thèse propose d’étudier les facteurs liés à la demande et à l’offre du dépistage du VIH en Côte d’Ivoire, dans un contexte d’épidémie mixte qui nécessite de considérer séparément le dépistage en population générale et le dépistage au sein de sous-populations très exposées au VIH.La thèse s’articule autour de deux axes :– Le dépistage en population générale qui pose les questions (i) du dépistage volontaire (à l’initiative du patient) afin de garantir un accès au dépistage à toute personne désireuse de réaliser un test et (ii) de l’accès au Conseil et dépistage à l’initiative du prestataire de santé (CDIP) lors de situations où le test est recommandé (grossesse, mariage, symptômes associés au VIH) ;– Le dépistage auprès des populations clés à travers l’exemple des HSH, qui pose les questions (i) du recours répété au dépistage (étant donné l’incidence du VIH élevée chez les HSH) et (ii) de l’adéquation du dépistage communautaire auprès des différentes populations HSH (cette forme étant privilégiée par les bailleurs pour atteindre les populations clés).L’originalité de cette recherche est son approche globalisante qui traite à la fois le point de vue de la demande (individus) et celui de l’offre (professionnels de santé), dont les barrières et leviers associés sont étudiés par le prisme d’un cadre conceptuel de l’utilisation du dépistage à travers quatre dimensions : l’information, les perceptions, les capacités et l’environnement.Ce travail s’appuie sur les résultats d’une méta-analyse, de deux revues systématiques de la littérature et de quatre enquêtes transversales réalisées en Côte d’Ivoire, dont certaines développent des méthodologies innovantes : enquête par téléphone à l’échelle nationale, Respondent Driven Sampling par téléphone. Ces quatre enquêtes, inscrites au sein de deux projets de recherche (DOD-CI ANRS 12 323 et PRECO-CI ANRS 12 277), considèrent quatre populations distinctes : population générale, soignants, HSH et personnes vivant avec le VIH.Les résultats de cette thèse montrent que les barrières au dépistage volontaire en population générale sont principalement liées à l’accès à l’information, au support économique (hommes), à l’autonomie dans le couple (femmes) et à l’environnement social (hommes).Le recours au dépistage lors de situations recommandées (grossesse, infections sexuellement transmissibles, mariage) reste faible, ce qui est principalement dû au fait que les professionnels de santé ne proposent pas systématiquement le test lors des consultations. Conséquences de ces opportunités manquées de dépistage, une partie des publics infectés ne sont pas diagnostiqués précocement.La pratique du CDIP par les professionnels de santé reste sous-optimale et les dimensions associées à leur pratique diffèrent selon la profession (médecin, infirmier, sage-femme).Le dépistage communautaire permet un dépistage large et répété d’une partie des populations HSH, mais il n’est pas toujours bien connu et accepté par l’ensemble des populations qu’il cible. Une partie des HSH lui préfère les offres indifférenciées de dépistage (« tout public »).En Côte d’Ivoire, l’amélioration du recours au dépistage en population générale et auprès des HSH nécessite : (i) une meilleure communication sur l’offre de dépistage, (ii) un renforcement de la proposition du test faite par les professionnels de santé lors des situations recommandées et (iii) le maintien d’une offre de dépistage « tout public » à côté de l’offre communautaire.
... Policy processes should identify sources (e.g., dedicated funds, general funds, donor funds) and levels of funding for implementation, including supply chain. (3,27,35,38,48,54,55,63,(67)(68)(69)(70)(71) In many countries, budget processes occur separately from policy processes led by ministries or departments of health. This bifurcation often leads to policies being adopted by ministries of health without clear costing analysis or, if costing analysis is conducted, adequate funds are not allocated during the budget process to effectively implement the policy. ...
The development and management of health policies, strategies and guidelines (collectively, policies) in many low- and middle-income countries (LMICs) are often ad hoc and fragmented due to resource constraints a variety of other reasons within ministries of health. The ad hoc nature of these policy processes can undermine the quality of health policy analysis, decision-making and ultimately public health program implementation. To identify potential areas for policy system strengthening, we reviewed the literature to identify potential best practices for ministries and departments of health in LMICs regarding the development and management of health policies. This review led us to identify 34 potential best practices for health policy systems categorized across all five stages of the health policy process. While our review focused on best practices for ministries of health in LMICs, many of these proposed best practices may be applicable to policy processes in high income countries. After presenting these 34 potential best practices, we discuss the potential of operationalizing these potential best practices at ministries of health through the adoption of policy development and management manuals and policy information management systems using the South Africa National Department of Health’s experience as an example.
Observing the impact of neocolonialism in education in the region of Sub-Saharan Africa (SSA), along with the high rates of inequality therein, the present paper endeavors to bring together these two factors and find a causal relation. With the aim of improving future research into the development and equalization of education in SSA countries, this research seeks to answer an unprecedented question: is there an impact of neocolonialism on educational inequalities in SSA in the last twenty years? Studying a sample of 45 states in this region, my hypothesis is that neocolonial dependency influences and worsens these inequalities.
I conduct a dual research, using (1) quantitative methods to study the impact that economic dependency on educational funding has on inequalities in educational access, and (2) a qualitative two-case study of didactic dependency in educational sectors and how this affects inequalities of opportunity and outcome in education. My hypothesis is partly confirmed: it is weakly supported by the study of the economic dimension of dependency, but strongly upheld in the case of the didactic dimension. All in all, the present paper shows promising leads for future large-scale research in this vein in SSA countries.
Social inclusion is the process of making it easier for people and groups to participate in society. African nations have taken the lead in several fields. For instance, of all the continents, Africa has implemented the most changes in favour of gender equality over the past 10 years. Positive developments have, like elsewhere in the world, not been equally distributed throughout Africa, with many areas and organizations have been forgotten. The goal of the chapter was to clarify what social inclusion is, reveal the causes of social exclusion in Africa, and come up with social inclusion strategies for the continent that can aid in sustainable development. It was emphasized that the neoliberal agenda of access views social inclusion as the first step towards a more inclusive understanding of social justice and human potential initiatives. The chapter also made clear that a social justice perspective provides a more inclusive definition of social inclusion. From the standpoint of social justice beliefs, it was emphasized that improving human rights, equality of opportunity, human dignity, and fairness for everyone is one way to improve social inclusion. The chapter’s conclusion emphasized the significance of social inclusion interventions from human potential empowerment interventions for advancing social justice concerns in Africa by ensuring that no one is left behind.KeywordsAfrica Social Inclusion Sustainable Development
There has been an increasing global interest in inequality in healthcare access. In Africa, the concept of inequality in healthcare access has been presented in different ways and used to inform various perspectives of individual and state actions. This chapter aims at examining how scholars, practitioners, and social activists have studied inequality in healthcare access in Africa. The implementation gaps in addressing inequality in healthcare access are also examined. We bring together various applications of methodologies and the nature of knowledge produced on inequality in healthcare access. Consequently, we highlight knowledge gaps regarding inequality in healthcare access in Africa, including social determinants and manifestations of inequality. Understanding the linkages in terms of dimensions of policy response that address structural limitations and hinder systems of equality in different African countries is vital. Most case studies depend on Demographic and Health Survey (DHS) and census data sets. Various data analysis approaches have been used depending on the researcher’s intention. We see no single theory that fits or explains all forms of inequality in healthcare access. We recommend a systematic review of why scholars preferred to study a particular perspective of inequality in healthcare access over another.
The COVID-19 pandemic is a reminder that insufficient income security in periods of ill health leads to economic hardship for individuals and hampers disease control efforts as people struggle to stay home when sick or advised to observe quarantine. Evidence on income security during periods of ill health is growing but has not previously been reviewed as a full body of work concerning low-income and middle-income countries (LMICs). We performed a scoping review to map the range, features, coverage, protective effects and equity of policies that aim to provide income security for adults whose ill health prevents them from participating in gainful work. A total of 134 studies were included, providing data from 95% of LMICs. However, data across the majority of these countries were severely limited. Collectively the included studies demonstrate that coverage of contributory income-security schemes is low, especially for informal and low-income workers. Meanwhile, non-contributory schemes targeting low-income groups are often not explicitly designed to provide income support in periods of ill health, they can be difficult to access and rarely provide sufficient income support to cover the needs of eligible recipients. While identifying an urgent need for more research on illness-related income security in LMICs, this review concludes that scaling up and diversifying the range of income security interventions is crucial for improving coverage and equity. To achieve these outcomes, illness-related income protection must receive greater recognition in health policy and health financing circles, expanding our understanding of financial hardship beyond direct medical costs.
Introducción: el deseo de recibir tratos favorables o preferenciales transgrediendo las normas y la ley origina comportamientos corruptos. El hecho de sobreponer el interés particular sobre el general incide en la sociedad, excluyendo a un porcentaje significativo de la población, que ve afectados sus derechos constitucionales. Este artículo reflexiona sobre el concepto de corrupción y revisa los actores del sistema de salud en Colombia, invitando a una mirada interdisciplinaria, capaz de una lectura crítica de la información que presentan los medios de comunicación.
Objetivo: hacer una reflexión sobre: 1) qué es la corrupción, 2) cuáles son sus causas, 3) cómo incide en el sistema de salud colombiano y 4) discutir la necesidad de una reforma profunda en la formación de los valores culturales que orienten hacia la valoración de la honradez y la transparencia.
Materiales y métodos: a partir de una revisión de fuentes secundarias, el artículo de reflexión señala cómo la corrupción afecta la salud pública. Se busca una aproximación conceptual a la noción de corrupción desde el punto de vista económico, político y cultural. Concluye, desde la perspectiva de la salud pública, con la necesidad de reformas profundas al sistema y de la formación de los profesionales de la salud como ciudadanos participativos con competencias para una lectura crítica de medios.
Resultados: se postulan tres premisas que, desde nuestro punto de vista, deben ser documentadas desde la academia: primera, la corrupción es universal; segunda, la corrupción ha penetrado en el sistema de salud, y, tercera, ha permeado de una manera más marcada debido al sistema de mercado sin regulación.
Conclusiones: la reforma al sistema de salud debe garantizar cero corrupción en el sector, acceso real a la provisión de servicios de buena calidad, con una mirada intersectorial que entienda el papel de los determinantes en salud en la perpetuación de la enfermedad y de la pobreza, y que tenga como meta de control los resultados bajo condiciones de equidad a corto plazo.
C hildren's right to health care is expressed in two sections of the South African Constitution. Section 27 accords "the right to have access to health care services for all South Africans". Section 28 (1) (c), which is that portion of the Bill of Rights dealing specifically with children's rights, states that children have "the right to basic health care services". This essay discusses the South African government's free health care policy and the extent to which it meets children's right to basic health care services, with a particular focus on the accessibility of services. The information in this essay comes from The Means to Live: Targeting poverty alleviation to realise children's rights, the forthcoming report on a three-year research project of the Child Poverty Programme at the Children's Institute, University of Cape Town. The Means to Live Project aims to investigate how government poverty alleviation programmes are targeted and the consequences of the targeting for children and their caregivers 1 – particularly where it results in very poor children being excluded from programmes. This essay is an abridged version of the more comprehensive discussion of the free health care policy in the full Means to Live report, to be released in 2007. (See the essay starting on page 31 for more details on this research project.) This essay focuses on the following questions: I What is free health care? I What is basic health care? I Are children accessing free health care? I What are the barriers to accessing health care? I What else impacts on health? I What are the conclusions? What is free health care? In 1994, during his first hundred days in office, former President Nelson Mandela announced the provision of free health care to children under six years and pregnant and lactating women as one of several programmes led by the Presidency. This initiative was coupled with an extensive clinic-building programme to ensure greater physical avail-ability of health care services to people in South Africa, especially for those who live in poverty. Free health care in South Africa currently means that services at public sector clinics and community health centres are free of charge for all people, and public sector hospital services are free for some groups of people. This policy was implemented in different stages since 1994. Initially, free health care was offered to all children under six and to pregnant and breastfeeding women making use of public sector health facilities including clinics, community health centres and hospitals. The exceptions are those children and women who are covered by medical aid or medical insurance and/or who live in households that earn more than R100,000 per year. Then, in 1996, free health care was extended to all people using primary level public sector health care services. More recently, in 2003, free hospital care was further extended to include children older than six with moderate and severe disabilities. The only type of public sector facility where some pay-ment must be made is public hospitals. The groups that have to pay for public sector hospital services are adults, children older than six who do not have disabilities and anyone covered by medical aid or medical insurance and/or who live in households that earn more than R100,000 per year. (Children's Institute) 1 Caregivers are those who undertake the primary responsibility for parenting children from day to day. In most, but not all, cases, this is the child's biological mother. Many children are cared for by grandparents, siblings, other relatives, or non-relatives. In the Means to Live, specific criteria were used to define one primary caregiver per child to replicate assessments of eligibility. In reality, however, care arrangements are often shared between parents or other household members.
The InterRegional Inequality Facility Secretariat: Overseas Development Institute 111 Westminster Bridge Road London SE1 7JD UK ii This study was sponsored by the InterRegional Inequality Facility. The Facility exists to promote interregional dialogue and knowledge sharing on the issue of inequality – how it affects development, and how it can be addressed by policy – between Africa, Asia and Latin America. The Facility funds research, exchanges and advocacy activities which strengthen South-South dialogue on this issue, and help build a coalition in favour of a more equal and inclusive development process.
We decompose changes in the Gini coefficient to investigate whether the Conditional Cash Tranfers (CCT) have had an inequality reducing effect in three Latin American countries: Brazil, Mexico and Chile. We conclude that CCT programs helped reducing inequality between the mid-1990s and the mid-2000s. The share of total income represented by the CCTs is very small, less than 1%. But as their targeting is outstanding, the equalising impact of CCTs was responsible for about 21% of the fall in Brazilian and Mexican inequality figures In Chile the effect was responsible for around 15% of the reduction.
The last decade has seen many of the 'community' concepts in health (community empowerment, community capacity) replaced by 'social' concepts (social capital, social cohesion). The continuous re-labelling of roughly similar phenomena may be a necessary stratagem to attract attention to the economic and power inequalities that arise from undisciplined markets. Social concepts also have an advantage over community ones by directing that attention to higher orders of political systems. The latest construct being wielded by health practitioners, researchers and policy-makers are the twinned concepts of social inclusion and social exclusion. These represent a conceptual sophistication over social capital and social cohesion. Like their predecessors, however, there are risks in their adoption without a critical examination of the premises that underpin them. For example, how can one 'include' people and groups into structured systems that have systematically 'excluded' them in the first place? The cautions expressed in this article do not dissuade use of the concepts. Their utility, however, particularly at a time when not only inequalities, but also their rate of growth, is increasing, requires careful questioning.
Africa harbours most of the poorest countries of the world because of so many factors such as internecine wars and ethnic strife, natural disasters, foreign debt corruption amongst several others. A reliable data also claimed that one out of every five Africans is a Nigerian. Presently, Africa owes 350 billion dollars, while Nigeria owes over 32 billion dollars. Despite the plethora of poverty alleviation programme which past governments had initiated and implemented, by 1999 when the Obasanjo administration came into power a World Bank's report indicated that Nigeria's Human Development Index (HDI) was only 0.416 and that about 70 percent of the population was vegetating below the bread line. These alarming indicators prompted the government to review the existing poverty alleviation schemes with a view to harmonising them to make them achieve the desired results. This paper examines the conceptual and institutional frameworks for tackling poverty in Nigeria. The paper also discusses the causes and effects of poverty in Nigeria. The paper is treated in four parts. Part one examines the definitions of poverty, the causes and effects of the prevailing and widespread poverty. Part two examines the social, political, environmental, technological and economical context of poverty and argues that all these factors are interlinked, and that no one area can be isolated for overall responsibility for the underlying causes of poverty in Nigeria. Neglect in one area would have consequences for the others. Part three examines institutional frameworks for tackling poverty in Nigeria, its strengths and inadequacies. Arguing that poverty has moved from its traditional monolithic understanding to a more complex or hydra headed one, part four of the paper makes recommendation for improvement towards alleviating poverty in Nigeria.
Poverty can be located within the context of contradiction between the resources available to an individual and the demand and condition of his/her environment. Poverty is a dreaded condition of absence of capacity to maintain at least basic level of decent living. It is a hydra headed condition which tends to restrict people from socio-economic opportunities. As a complex and multi dimensional phenomenon, poverty goes beyond condition of lack of resources; it extends to social inequality, insecurity, illiteracy, poor health, restricted or total lack of opportunity for personal growth and self realization. Onibokun and Kumuyi (1996) made the point when they defined poverty as 'a way of life characterized by low calorie intake, inaccessibility to adequate health facilities, low quality education, inaccessibility to various housing and societal facilities (p.3). Individuals who are victims of poverty are usually referred to as poor while nations suffering from it are called poor nations. According to UNDP (1998), the poor are those who are unskilled and unemployable who, as a result of little or no income, are totally dependent on others for the satisfaction of their daily needs. Poor countries are marked mostly by low productivity, alarming high population growth rate and pronounced gap between the haves and the haves-not especially in terms of access to health facility; quality and quantity of food intake and wide urban-rural divide. The growth of poverty among the countries within the developing economy has assumed an epidemic proportion, so much so that poverty reduction took centre stage in the United Nations millennium development goals. The 191 member nations of the organisation have collectively resolved that by 2015, extreme condition of poverty and hunger will be eradicated. In addition, the proportion of those living on less than a dollar a day and those suffering from hunger would be halved (UNDP 2003).
The first part of this paper provides an analysis of poverty and destitution in the cities of Mozambique. The second part summarises the existing programmes for poverty alleviation and the social safety net. The last part describes in some detail the only organisation and programme which has had significant impact in terms of alleviating poverty and destitution: the Gabinete de Apoio a População Vulnerável (GAPVU) Cash Transfer Scheme.A poverty profile of Mozambique's urban centres shows that over half of all households are living in poverty. It distinguishes between absolutely poor and destitute households. The latter have expenditures less than two thirds of the poverty line, are at risk of malnutrition, high child mortality and low life expectancy and comprise nearly a third of the population. A distinction is made between structural and conjunctural causes of poverty and used as a basis for classifying households in different situations, in order to identify appropriate types of intervention. Existing policies and programmes to reduce poverty and alleviate destitution are reviewed and their strengths and weaknesses identified. The cash transfer scheme designed and operated by the GAPVU is described in more detail, and its effectiveness in reaching destitute households assessed. Finally, its administrative efficiency and financial and institutional sustainability are evaluated. It is shown to be a well designed programme which succeeds in reaching increasing numbers of vulnerable households because of its use of decentralised health and community administrative structures, and strong political and institutional backing.
Incluye bibliografía e índice A la cabeza del título: Commission on Social Determinants of Health final report