Combining health and social protection measures to reach the ultra ...

Access to healthcombining participatory wealth ranking exercises with thevillagers and verification by a brief household survey. A set ofinclusion and exclusion criteria ensured that only householdswhich have been by-passed previously by any kind ofdevelopment inputs from any source are selected 25 .Once selected, the women members of the ultra poorhouseholds were provided with two or more incomegeneratingenterprise options including poultry rearing,livestock, vegetable farming, horticulture nursery, and nonfarmactivities (value range: US$ 50–150). Other non-healthinputs were: subsistence allowance (@ US$ 0.17 daily);skill-development training (e.g., poultry/livestock rearing,vegetable cultivation, shoe-making etc.); social awarenessdevelopment and confidence building training; and pro-pooradvocacy for involving the rural elites 26 .The health support was tailored specifically to overcomedifferent demand-side barriers faced by the poor, especiallyultra poor, to access health care services 27 . These comprisedof: EHC services with free installation of latrines and tubewells(to develop health awareness and change “unfelt need”to “felt need”), consumer information on locally availablehealth services (to overcome information barrier), identitycard for facilitated access to formal health facilities (toovercome social exclusion), and financial assistance fordiagnostics and hospitalization, if needed, throughcommunity mobilized fund (to overcome financial barrier) 28 .Impact assessmentCFPR/TUP was designed as an experimental programme toaddress some of the most complex economic and socio-politicalconstraints facing the ultra poor in Bangladesh. The basicmodel of careful targeting, asset transfer, skills development,intensive technical assistance along with customized healthsupport has in general worked quite well as reflected in thevarious assessments carried out both internally by BRAC’sResearch and Evaluation Division 29 and external evaluators 30 .Impact on livelihoodFindings reveal that the majority of the participating ultra poorhouseholds improved their poverty status following theintervention. Using the conventional extreme economic1001 Dollar a daySocialNaturalNSUP02NSUP05Physical10.50FinancialSUP02SUP05HumanFigure 2: Changes in different assets during 2002–2005(Rabbani et al. 2006)poverty line of one dollar a day, we find that in 2002 theproportions of extreme poor were 89% and 86% for selectedultra poor households, SUP (top 1st line) and not-selectedultra poor households, NSUP (top 2nd line) householdsrespectively (Figure 1). It has gone down to 59% for the SUP(bottom broken line) but only to 73% for the NSUP in 2005(broken line above the previous line) 31 .Five types of assets formed the basis of a household’ssustainable livelihood in this evaluation and is represented inan asset pentagon (Figure 2). These assets are: financialassets (savings and credit), human assets (earner-memberration, average years of schooling of household members,percentage of household members without any disability,percentage of household members who have not suffered anyillness in the last 15 days from the day of interview), physicalassets (productive assets, furniture, tube-well, ornaments/jewellery, value of homestead), natural assets (landownership), and social asset (whether household membersreceived any invitation from neighbours) 32 . The asset pentagonin Figure 2 visually displays the relative changes over thethree-year time period of these assets among the SUP andNSUP households. It can be seen that SUP households haveovercome their initial deficiencies in most categories excepthuman assets, and have managed a stronger asset base thanthe NSUP households. The lack of change in this categoryreiterates the fact that investment in human asset is along-term process.806040200Per capita annual incomeFigure 1: Per capita income in 2002 and 2005GroupsSUP 02NSUP 02SUP 05NSUP 05(Rabbani et al. 2006)Impact on nutrition and food securitySimultaneously, the food security status of the householdsimproved (Figure 3). In 2002, over 60% of the SUP reportedchronic food deficit, the rest had occasional deficit, and onlya few SUP households broke even. Food deficit is also highlyprevalent in 2005, but the extent of chronic food deficiencyhas fallen for both groups. The quantity and quality of thefood consumed also improved during the study period 33 . A31% increase in food intake, and 9% increase in energy intakeoccurred in the SUP households while there was only 1%increase in food intake and 10% decline in energy intake forthe NSUP households.Global Forum Update on Research for Health Volume 4 ✜ 035