Health as a dimension of poverty
The right to health is protected in Article 25 of the Universal Declaration of Human Rights and Article 12 of the International Covenant on Economic, Social and Cultural Rights. The World Health Organization (WHO) identifies the four core components of the right to health as availability, accessibility, acceptability and quality. SDG 3 aims to ‘ensure healthy lives and promote well-being for all at all ages’. This goal recognises that wellbeing includes both physical and mental health.
What the research reveals about health
Poor health can reduce an individual’s ability to work and receive an income, while also draining household resources (Narayan et al., 2000). A household may experience a decrease in income if the unwell person is an adult or is cared for by an adult household member (WHO and World Bank, 2011). The cost of health care is a major barrier to access. Strategies to pay for health care include borrowing, relying on family assistance, and drawing upon assets and savings (Sparrow et al., 2014). In low- and middle-income countries, patients often do not seek care or seek care only when financial resources are available (Goudge et al., 2009).
Goudge et al. (2009: 76) identify the key barriers to health care as ‘unaffordable costs to households, weak availability of inputs and services, and poor acceptability (the appropriateness of the social interaction that accompanies care)’. The social interactions that accompany health care are rarely measured within poverty assessments, but are essential in understanding the relationship between poverty and health care. A report by WHO, the World Bank and the OECD (2018) suggests identifies inaccurate diagnosis, medication errors, inadequate or unsafe clinical facilities or practices, and practitioners who lack adequate training and expertise as factors that undermine progress towards better health outcomes.
Mental health has become increasingly important to the international development agenda as it is fundamentally linked to other health outcomes as well as physical and social functioning. WHO (2019) states that ‘mental health conditions can contribute to poor health outcomes, premature death, human rights violations, and global and national economic loss’ and has increased its efforts to scale up related programs. The link between poverty and mental health is complex; however, it is evident that correlates of poverty (e.g. food and housing insecurity, low levels of education) contribute to mental health disorders (Kuruvilla and Jacob, 2007). Furthermore, there is potential economic burden from mental health disorders in the form of associated long-term costs and a lack of productivity.
What the IMMP reveals about health
Various measures of poverty, deprivation and wellbeing assess aspects of health. One of the three dimensions of the Human Development Index is health, using life expectancy as a proxy. The global Multidimensional Poverty Index also includes health as one of its three dimensions, with two health indicators measuring undernourishment and child mortality (Oxford Poverty and Human Development Initiative, 2018). These measures do not assess quality, access or acceptability of health care.
In the development of the IMMP, participatory research revealed two aspects of health as being of particular importance: health status and health care utilisation. Health status reflected the short-term or chronic conditions experienced; participants emphasised the impact of poor health on other life circumstances. The main issues identified in relation to health care utilisation were the accessibility of health care (seen as both a demand and a supply issue) and the quality of the health care utilised.
What the IMMP Health dimension measures
The health dimension of the IMMP consists of two themes: health status, and health care access and quality.
Theme 1: Health status
The first theme consists of two indicators: physical health status and psycho-social health status.
The physical health status indicator has three variables, which consider the presence of recent conditions of injury or illness, long-term conditions, and health problems caused by exposure to fuel smoke. (Recent conditions are those experienced in the 4 weeks preceding the survey, while long-term conditions are those which the respondent has experienced within the past 12 months, which lasted 6 months or longer.)
The psycho-social health status indicator within this theme draws on two variables to capture how frequently the individual felt worried, nervous or anxious, and/or felt depressed. These questions are drawn from the Washington Group extended set on psycho-social distress (Washington Group, 2017).
Theme 2: Health care access and quality
The second theme is constructed from two indicators: access to general health care, and access to pre-natal health care.
The first indicator is made up of three variables: whether an individual has accessed a health care facility in the past twelve months; reasons for not accessing health care; and the number of problems an individual experienced when accessing a health care facility. Possible problems faced include the skills and knowledge of the health care practitioner, the cleanliness and location of the health care facility, and the experience of the individual (i.e. whether the medical staff treated them with respect and the clarity of communication by the health practitioner). A 12-month time frame is used to ensure that the information collected reflects both routine as well as urgent and emergency health care.
The second indicator captures information about pre-natal care from female respondents who were pregnant at the time of the survey or who had given birth in the preceding 12 months. The three variables that make up this indicator are whether pre-natal care was received during past pregnancies, the number of visits during past pregnancies; and (if the respondent is currently pregnant) whether she is currently receiving pre-natal care.