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©INTERNATIONAL CENTRE FOR DIARRHOEAL
DISEASE RESEARCH, BANGLADESH
J HEALTH POPUL NUTR 2009 Aug;27(4):528-535
ISSN 1606-0997 | $ 5.00+0.20
Capability Development among the Ultra-poor in
Bangladesh: A Case Study
Syed Masud Ahmed
Research and Evaluation Division, BRAC, BRAC Centre,
75 Mohakhali, Dhaka 1212, Bangladesh
ABSTRACT
Microcredit is advocated as a development tool that has the potential to reduce poverty, empower partici-
pants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor,
often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan
they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention
directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention
integrates multiple components, including asset grants for income generation, skills training, a time-bound
monthly stipend for subsistence, social development and mobilization of local elite, and health support. Re-
sults of an evaluation showed that, after 18 months, the programme positively impacted livelihood, econo-
mic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and
joined (or intended to join) a regular microcredit programme. Impacts included improved income, im-
proved food security, and improved health knowledge and behaviour. Applying a social exclusion frame-
work to the intervention helps identify the different dynamic forces that can exclude or include the ultra-
poor in Bangladesh in development interventions such as microcredit.
Key words: Capacity-building; Economic assistance; Poverty; Ultra-poor; Bangladesh
Correspondence and reprint requests should be
addressed to:
Dr. Syed Masud Ahmed
Research Coordinator
Research and Evaluation Division, BRAC
BRAC Centre
75 Mohakhali, Dhaka 1212
Bangladesh
Email: ahmed.sm@brac.net
INTRODUCTION
In Bangladesh, the proportion of population fall-
ing below the lower poverty-line (corresponding to
the consumption of 1,805 kcal per capita per day)
is variously termed as ‘extreme poor’, ‘hardcore
poor’, or ‘ultra-poor’, and this comprises around
20% of the population (1,2). The ultra-poor are
characterized by their inability to participate fully
in social and economic activities and in decision-
making that has an impact on their daily lives. This
social exclusion denies them the consumption of
essential goods and services, such as healthcare,
that are available to other segments of the popu-
lation (3,4). These households have a few or no
assets, are highly vulnerable to any shock, such
as natural disasters, death, or disability of an in-
come-earner, illnesses requiring costly care, and
mainly depend on wage-labour for survival. Their
disadvantaged condition makes them vulnerable
to differential treatment by the health system as
well (5,6). The income-erosion effect of ill-health
for the poor households, especially the bottom 15-
20%, is well-documented in Bangladesh (7). This
may occur through loss of income due to illness,
catastrophic health expenditure, and potentially-
irreversible crisis-coping mechanisms that involve
asset and savings depletion (8,9).
Factors that contribute to the differential levels of
poverty are not straightforward, are typically mul-
tiple, and can include health status and access to
social, cultural, political and economic capabili-
ties and resources. This case study describes the re-
cent programme of BRAC (www.brac.net; www.
brac.net/research) for the ultra-poor population
which was designed to address their multiple layers
of deprivation. A review of findings of evaluation
studies on the programme demonstrates that, by
incorporating multiple elements that promote in-
clusion, such as access to services (including health
services), income-generating assets and skills, and
strengthened social networks, the ultra-poor can
emerge from extreme poverty.
Ahmed SMUltra-poor in Bangladesh
Volume 27 | Number 4 | August 2009 529
THE CFPR/TUP PROGRAMME
To improve the health and livelihood status of the
poor, BRAC, an indigenous Bangladeshi non-govern-
mental organization (NGO), has integrated a number
of capability-enhancing activities into microcredit-
based income-earning interventions. These include
human capital development, promoting gender
equity, and building legal awareness, in addition to
customized health interventions. This is termed a
‘credit plus’ approach as opposed to the ‘credit
only’ approach of many other NGOs. Nonetheless,
grassroots experience in more than three decades has
shown that regular microcredit-based interventions
as implemented by BRAC are not sufficient to ef-
fectively reach the most vulnerable section among
the poor, i.e. the ultra-poor, for a number of rea-
sons. Included among these are some structural fac-
tors, such as harsh discipline of the microcredit/mi-
crofinance institutions, which are unsuitable to the
minimal and irregular access to resources among
the ultra-poor, fear of cash money transactions,
and absence of a safety-net provision in the pro-
gramme (10). Experiences gained from working with
these population groups in recent years (11,12) were
used for developing a customized grants-based inter-
vention—which included a health intervention for
mitigating the income-erosion effect of illness—by
BRAC under the name “Challenging the frontiers of
poverty reduction/targeting ultra-poor, targeting
social constraints” (CFPR/TUP) (13). The interven-
tion was undertaken to develop and test a model of an
integrated health and social protection intervention
for the ultra-poor. [The CFPR/TUP programme was
funded by a donor consortium which includes: Ca-
nadian International Development Agency, UK De-
partment for International Development, European
Commission, NOVIB, and World Food Programme].
Launched in 2002, the first phase of the interven-
tion covered all 21 upazilas (an administrative unit
covering about 250,000 population) of the three
purposively-selected famine- and/or flood-prone
districts (Rangpur, Kurigram, and Nilphamari) in
northern Bangladesh. From previous poverty-map-
ping, these districts were found to have the highest
concentration of extreme poor households in the
country (14). In implementing this CFPR/TUP in-
tervention, BRAC expected that, through the devel-
opment of social, economic and political resources
and capabilities, and with access to a healthcare
safety-net, the ultra-poor population would be able
to attain a sustainable livelihood and subsequently
participate in and benefit from mainstream micro-
credit programmes.
Components of the CFPR/TUP programme
Initially, the programme selected villages in upazi-
las with a high concentration of poor households
based on local-level knowledge of BRAC field staff
at area offices. Villagers identified the ultra-poor
households in participatory economic wealth-
ranking exercises, verified later in a brief household
survey by BRAC field staff against programme-set
targeting criteria which included both inclusion
and exclusion conditions (Table 1).
Households were excluded from the intervention
if they accessed specific economic resources from
the Government of Bangladesh or from NGOs
and were included if they had two or more condi-
tions of severe economic exclusion. The exclusion
criteria were mandatory to ensure that the house-
holds previously bypassed by development inputs
be included in the intervention. The selection
was cross-checked by senior staff through on-site
evaluation, yielding a final list of households (for
Table 1. Programme set final selection criteria (15)
Criteria for selecting ultra-poor households
Exclusion conditions (All selected
households with these conditions will
be excluded)
The household borrowing from a microcredit-providing
NGO
The household receiving benefits from government prog-
rammes
Inclusion conditions (At least two of
these conditions will have to be satis-
fied)
Total land owned less than 10 decimals
Adult women in the household selling labour
Household’s main male income-earner is disabled or not able
to work
Households where school-going children have to sell labour
Household has no productive assets
NGO=Non-governmental organization
Ahmed SM
Ultra-poor in Bangladesh
JHPN
530
intervention) from all programme villages under
the three districts (2). Once selected, the female
members of the ultra-poor households were pro-
vided with two or more income-generating enter-
prise options, including poultry-rearing, livestock,
vegetable farming, horticulture nursery, and non-
farm activities. Necessary materials and training
were provided as grants, along with customized
health and other support which were delivered
over an 18-month cycle (Table 2). During this
18-month period, the income-generating capa-
bilities and resources of the project participants
were expected to improve, a social development
component was expected to enhance social ca-
pabilities, and political resources and capabilities
were expected to develop via a mobilization of the
local elite for project support.
Experiences have shown that the poor, especially the
ultra-poor, are often not able to take full advantage
of official free services provided under existing es-
sential healthcare (EHC) package at BRAC and gov-
ernment primary-level care facilities. [The package
comprises maternal health, family planning, com-
municable disease control, child health, and basic
curative care (13)]. Factors that barred people from
accessing health services included lack of access to
information on available services (information bar-
rier), lack of health awareness (unfelt need), lack
of opportunity (exclusion from social and health
institutions), and inability to pay (economic exclu-
sion). Given the empirical evidence of the potential
of microcredit programmes to improve health in
Bangladesh (16-19), the health component of the
CFPR/TUP programme was tailored specifically
to overcome these barriers. Thus, the customized
health intervention acted as safety-net against
the income-erosion effect of costly morbidities
(Table 3).
Table 4 gives a brief overview of the outreach of
the programme in 2002. In 38 area offices of the
three districts, 1,014 participatory wealth-rank-
ing (PWR) exercises were conducted. According
to these wealth rankings, a little over 25% of the
households (n=23,521) were identified as the ul-
tra-poor. Using the selection criteria mentioned
above, nearly one-fifth (n=5,000) of these ultra-
poor households (n=23,521) were taken into the
programme (20).
Review of CFPR/TUP impact-assessment
studies
The CFPR/TUP model of careful targeting, asset
transfer, skills development, intensive technical
assistance, along with customized health support,
was found in general to have worked quite well.
This was reflected in various evaluations carried out
by the Research and Evaluation Division (RED) of
BRAC (20,21). RED is an independent entity within
BRAC primarily mandated to provide research sup-
port for programme design and improvement. The
evaluation by Rabbani et al. adopted a quasi-experi-
mental design and comprised a baseline survey in
Table 2. The CFPR/TUP programme components and its rationale (15)
Component Rationale
Integrated targeting methodologies Effective targeting of the extreme poor
Income-generating asset transfer
[Range: Tk 3,000-9,000 (US$ 50-150)]
Build economic asset base
Income-generation skill training and regular
refreshers, e.g. poultry/livestock-rearing, vegetable
cultivation, shoe-making, etc.
Ensure good return from asset transferred
Technical follow-up of enterprise operations Ensure good return from asset transferred
Provision of all support inputs for the enterprise Ensure good return from asset transferred
Monthly stipends for subsistence
[Tk 10 (US$ 0.17) daily for 12-15 months]
Reduce opportunity cost of asset operations
Social development, e.g. social awareness and
confidence-building, legal awareness, social action
on early marriage/dowry, etc.
Knowledge and awareness of rights and justice
Mobilization of local elite for support (pro-poor
advocacy through seminar, workshop, and popu-
lar theatre)
Create an enabling environment
Health support Reduce costly morbidity
Ahmed SMUltra-poor in Bangladesh
Volume 27 | Number 4 | August 2009 531
2002 and an endline survey in 2005 at the end of
intervention cycle plus a one-year grace period to
settle down the effects of intervention (20). House-
holds selected for intervention were termed ‘select-
ed ultra-poor (SUP) households’, and households
which were equally poor but not selected due to
exclusion criteria, such as receiving any safety-net
benefits and, therefore, marginally better in eco-
nomic conditions, were considered a comparison
group and were termed ‘not-selected ultra-poor
Table 3. Health support under the CFPR/TUP programme with rationale (22)
Component Rationale
Essential healthcare (EHC)* package, installation of
sanitary latrines and tubewells free of charge
Developing health awareness, change ‘unfelt
need’ to ‘felt need’ and control disease transmis-
sion
Consumer information package on locally-available
health services
To overcome information barrier
Identity card (health card) for facilitated access to
heath services
To overcome barrier due to social exclusion and
promote use of formal health services
Financial assistance for costly morbidity, e.g. illness
requiring inpatient treatment or costly laboratory
tests, from fund mobilized by programme and com-
munity
To overcome financial barrier
Intensive supervision and assistance from commu-
nity health volunteers and health staff to avail of ser-
vices; developing referral network for severe illnesses
To optimize opportunity cost of accessing and
attending healthcare services
*Health and nutrition education, child immunization, pregnancy care, basic curative care for common
illnesses at cost prices (or free of charge if unable to pay), and delivery of DOTS (directly-observed treat-
ment, short course) for patients with tuberculosis
Table 4. Programme outreach in 2002 and the survey by district (20)
Indicator Rangpur Nilphamari Kurigram Total
Number of area offices 15 12 11 38
Total number of PWRs held 370 332 312 1,014
Total number of households in PWRs 34,522 28,591 28,897 92,010
Number of the ultra-poor in PWRs 7,966 6,137 9,418 23,521
(% of total households) (23.08) (21.40) (32.59) (25.56)
Number of households selected through
inclusion-exclusion criteria 3,133 2,605 2,782 8,520
Number of households finally selected after
verification 2,474 1,812 2,541 6,827
Number of households taken into the pro-
gramme 1,853 1,401 1,746 5,000
(% of total households in PWRs) (5.38) (4.90) (6.04) (5.43)
Baseline survey
Area offices 15 12 11 38
Spots (PWRs) in survey 137 92 97 326
Households interviewed in the baseline
survey
Beneficiary
Non-beneficiary
Total
843
935
1,778
827
864
1,691
963
1,194
2,157
2,633
2,993
5,626
PWRs=Participatory wealth-rankings
Ahmed SM
Ultra-poor in Bangladesh
JHPN
532
(NSUP) households’. However, the two groups
were comparable in health-related matters (Table
5). The NSUP households were the closest group to
the SUP households for meaningful comparison.
It was assumed that, without the supports the SUP
received, the gap between the SUP and the NSUP
would have remained the same. Therefore, any re-
duction in the gap was considered the impact of
the programme. In other studies, this problem of
different baseline values was efficiently handled in
the analysis by estimating the effect of the inter-
vention as an interaction term in a longitudinal
model using the Proc Mixed procedure in the SAS
software (8.2 version) (23).
groups of households did not have the same initial
endowment with respect to economic condition.
As the NSUP households were marginally better-off
due to receipt of government benefits, these house-
holds had a propensity to improve their economic
status, although not at the same level as the SUP
households which received customized and varied
CFPR/TUP inputs.
The improvement in poverty status was also re-
flected in improved asset base of the ultra-poor
households (20). Five types of assets formed the ba-
sis of sustainable livelihood of a household in this
evaluation: financial assets (savings and credit), hu-
Table 5. Characteristics of study households at baseline in 2002 (23)
Characteristics
Ultra-poor households
Intervention
(n=2,189)
Comparison
(n=2,134)
% of households owning homestead land*45 56
% of households not owning any cultivable land*55 43
% of households reporting chronic deficit round the year*64 44
% of households with a literate head*712
% of households with a female head*42 28
For major illness episode of sick person (15 days recall)
% seeking self-care (no treatment + self-treatment) 46 38
% treatment-seeking from ‘formal allopathic’
(paraprofessionals + professional allopaths) providers 23 25
% spending more than Tk 25 for recent illness 30 39
*Differences are statistically significant at 1% level
At baseline in 2002, the size of SUP and NSUP
households was, respectively, 2,633 and 2,993 (to-
tal=5,626). In 2005, the number decreased (about
5%) to 2,474 SUP households and 2,754 NSUP
households (total=5,228) due to attrition from
death, migration, and absence of a respondent after
three repeated visits (20). Some key findings from
these studies are discussed below.
Improvement in poverty status
The findings revealed that the majority (69%) of
the participating ultra-poor households improved
their poverty status following the intervention
(20). Using the conventional extreme economic
poverty-line of one dollar a day, the authors found
that, in 2002, the proportions of the extreme
poor were 89% and 86% for the SUP and the
NSUP households respectively. It has gone down
to 59% for the SUP households but only to 73% for
the NSUP households in 2005. The decrease in the
non-intervention area occurred because the two
man assets (skills, education, and health), physical
assets (productive, e.g. livestock and poultry, and
unproductive, e.g. furniture and tubewell), natural
assets (land ownership), and social assets (whether
household members received any invitation from
neighbours). The authors traced the relative chang-
es over the three-year period of these assets among
the SUP and NSUP households. They found that
the SUP households have overcome their initial de-
ficiencies in most categories and have managed a
stronger asset base than the NSUP households, ex-
cept for human assets. The lack of change in this
category reiterates the fact that investment in hu-
man assets is a long-term process.
Improvement in nutritional status
Simultaneous with economic improvement, food
and calorie consumption among the SUP house-
holds increased significantly during 2002-2004
(during intervention), and the upward trend con-
tinued in 2006 (24). Improvements were observed
Ahmed SMUltra-poor in Bangladesh
Volume 27 | Number 4 | August 2009 533
in both quantity and quality of food intake. The
overall level of food consumption among the SUP
population (748 g per capita per day) was higher
than the national average for the bottom 20% (721
g per capita per day). On average, the calorie gap
from recommended dietary allowance was eight
percentage points lower for the SUP compared to
the NSUP. Interestingly, the SUP female-headed
households had a significantly higher total food
and calorie intake than the SUP male-headed
households. This was reverse in the case of the
NSUP households. Beneficiary households had
more diversified diet with a significant amount of
foods of animal source and spent more for food
consumption.
Improvement in use of health services and
healthcare-seeking behaviour
By increasing the capacity for health expenditure
and facilitated access to public-health facilities,
the programme increased the possibilities of use of
health services among the study households as re-
flected in the substantial reduction of self-care and
increased healthcare-seeking from different formal
allopathic care providers (medical graduates and
paramedics) during illness (23). This happened,
presumably, through activities in the intervention
to overcome specific demand-side barriers (e.g. in-
formational, financial and social barriers) that
excluded them from accessing healthcare. Be-
sides changes in healthcare-seeking behaviour,
the intervention also succeeded in improving
consumer information on available health ser-
vices, perceived self-health of the female mem-
ber, child’s nutritional and immunization status,
and use of contraceptives (22,25).
Importance of health components in the CFPR/
TUP programme
The research design did not allow evaluation of
the relative importance of economic versus the
health programme support and the social, po-
litical and cultural capabilities enhancing com-
ponents. However, the authors in another study
on the same group of participating women ex-
ploring factors underlying the change found that
“health is a major factor in determining change
in the TUP programme” (26). They concluded
that, if participants cannot work due to poor
health and nutrition, they are never likely to see
a significant change that is sustainable. The find-
ings also support the hypothesis that an interven-
tion that includes health and social protection
measures in addition to economic resources and
capability development, typical of microcredit
programmes, would be more likely to succeed
among the very poor (27).
Impact of the programme from community
perspective
The above empirical findings were also reiter-
ated by a study which examined the impact of
the programme from a community perspective
(21). The study used community-based change-
ranking exercises to explore changes following
the intervention and found a ‘strong evidence
of programme impact’ in bringing about posi-
tive changes in their lives from the perspectives
of the community. These changes were ‘small’,
plausibly so, given the initial conditions of the
ultra-poor households. The probability of being
ranked in the ‘improved’ category by the com-
munity in 2005 was 45 percentage points higher
for the SUP households compared to the NSUP
households where both had similar household
characteristics in 2002. During the change-rank-
ing exercises, the community identified five ‘top’
reasons of improvement as being industrious
with current occupation (35%), involvement in
new income-generating activities (18%), supervi-
sion from the programme (12%), the increased
number of earners in household (11%), and as-
sistance from relatives (5%) (19). Similarly, the
‘top’ five reasons of deterioration in participa-
tory wealth-ranking identified by them were:
ageing and deteriorating health (17%), marrying
off daughter (16%), fewer income-earners com-
pared to household size (15%), health expendi-
ture (7%), and decrease in the number of earners
(6%) (21).
Sustainability
At the end of the intervention period, around 55%
of the ultra-poor households participating in the
intervention were able to join the mainstream de-
velopment programme of BRAC and take micro-
credit loans to continue with their income-earning
enterprises (28). They also continued to receive
regular EHC services provided by the mainstream
microcredit programme. The authors concluded
that, with a lower borrower-member ratio and rela-
tively smaller-sized credit taken by these ‘graduat-
ed’ ultra-poor members, microcredit/microfinance
for the poorest may take a longer time to achieve
sustainability.
Thus, the CFPR/TUP model at as little as US$ 278
per household per 18-month cycle (US$ 15 per
Ahmed SM
Ultra-poor in Bangladesh
JHPN
534
month) could positively impact: (a) livelihood (im-
proved income and asset base) and (b) economic,
social and health status (positive changes), and
maintenance of asset growth after ‘graduation’ and
joining the regular microcredit/microfinance pro-
gramme (28).
LESSONS LEARNT
Lessons learnt from the CFPR/TUP model for repli-
cation and scaling-up include the necessity of em-
ploying a multi-pronged approach to develop the
capabilities and resources of the ultra-poor neces-
sary for overcoming exclusion and adopting a sus-
tainable livelihood. By careful identification of the
ultra-poor households, the intervention facilitated
access to locally-available services, such as public-
sector health facilities through use of identification
(health) cards. The grants and the skill training
helped them access and build productive assets. Fi-
nally, the feasibility and necessity of mobilizing the
better-off section of the community (village elites)
for inclusion of the ultra-poor in the mainstream
society is also amply demonstrated.
CONCLUSION
Reducing poverty through specific targeting of
the disadvantaged groups, such as the ultra-poor,
with customized services is possible and is urgently
needed in Bangladesh. In doing so, the following
have to be taken into account:
● A combination of components that includes
development of health, sociocultural, political
and economic capabilities and livelihood-pro-
tection measures in an intervention can be ef-
fective in overcoming the exclusion (including
exclusion from essential services, such as health-
care) faced by disadvantaged populations
● Customized health interventions (with finan-
cial help as and when needed) are necessary to
reduce health shocks and the implications these
have on household finances on the way to sus-
tainable livelihood.
However, there is a danger that the targeting ap-
proach followed for identifying the ultra-poor, for
example, the requirement that at least one physi-
cally-able woman is available in the household
can bypass the extremely-vulnerable destitute, for
example, those too weak to engage in productive
activities. Special safety-net programmes will be
needed for such population subgroups.
ACKNOWLEDGEMENTS
This work was funded by the World Health Orga-
nization (WHO) and undertaken as work for the
Social Exclusion Knowledge Network established
as part of the WHO Commission on Social Deter-
minants of Health. The views presented in this pa-
per are those of the author and do not necessarily
represent the decisions, policy, or views of WHO or
Commissioners.
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