Do the poor benefit from infectious disease programmes?

2 Jun 2010

Paul Chinnock

Source: TropIKA.net Journal (see original article or PDF)

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Citation: Thiede MH, Castillo-Riquelme M (2010). How pro-poor are infectious disease programmes? TropIKA Reviews; 1(1).

Background

Infectious diseases and poverty are closely linked in a vicious circle; the poor are more likely to become sick and when they are ill their poverty worsens. When a programme is introduced to improve prevention or treatment of an infection, it is assumed that this will help everyone in the community – particularly the poor, who are at greatest risk of acquiring the disease. However, studies have found that deprived groups may benefit less from these interventions than the general population.

This has led to much discussion about the need for infectious disease and other health care interventions to be specifically “pro-poor”. This term is often used very loosely and has never been precisely defined, but it is clear that it is not enough for an intervention to be of some help to low-income groups; the level of benefit to the poor should be assessed in the context of their needs, which are greater than those of other income groups.

Why was this review done?

Recent years have seen an increase in research devoted to the infectious diseases of poverty. Effective new ways to control many of these diseases have been developed and are now being put into practice. Malaria is one example; a range of new “tools” to fight this disease have been introduced. But even the most effective interventions will be of limited use if they do not reach the people who need them most – the poor. It is important that policy makers should know whether interventions are achieving this goal and what can be done to maximize the level of “pro-poor effectiveness”.

What did the researchers do and find?

They searched the scientific literature for research evaluating the success levels of infectious disease control programmes in which one of the stated intentions was that the poor should benefit from the implementation of the programme. They did so by conducting electronic searches of scientific databases. To find studies of this type, they searched for the appearance of one or more of the terms “pro-poor”, “equity”, “socioeconomic” or “access”. The study reports also had to include the terms “communicable diseases”, “tuberculosis”, “malaria” or “HIV infections”; and “intervention”, “programme”, “strategy”, “treatment” or “control”.

In advance of the search, the authors defined certain criteria that studies must meet in order for data from them to be included in their review. The focus of each paper had to be on infectious diseases in a developing country context, and to have specifically addressed the issue of poverty or to have reported results by socioeconomic status. A comprehensive description of the intervention and a discussion of its sustainability were also required, so that the reviewers could assess the strength of the evidence provided by the study.

The electronic searches produced 826 potentially relevant papers but after inspection only 89 were found to meet the criteria for inclusion. Nearly all the information available was on just three diseases – malaria, tuberculosis and HIV/AIDS. The data supported current understanding that poor people are more likely to suffer from these infectious diseases.

Most of the studies on malaria addressed preventive interventions, mainly the distribution of insecticide-treated bednets (ITNs); in most cases the relatively better-off tended to benefit more, though there were a few instances of programmes where inequalities in ITN use had been reduced. Other studies found that, for example, children with malaria from the poorest families were less likely to be taken to health care facilities for treatment than other children; improvements in malaria care were therefore more likely to be of benefit to better-off families.

The findings on TB interventions were more encouraging. Some of the included studies demonstrated that, if TB treatment is provided within primary health care programmes and communication with patients is improved, then inequalities between income groups can be reduced. The data on HIV/AIDS was hard for the reviewers to interpret; many studies reported results from interventions within narrow geographical areas characterized by poverty, and successes had been automatically assumed to reflect pro-poor effectiveness; the reviewers believe that more evidence from research is needed before reliable conclusions can be drawn.

What do these findings mean?

The authors conclude that, “Our review demonstrates that the pro-poor effectiveness of infectious disease interventions has neither been a priority in programme development nor has it been addressed articulately in research”. The difference in the goals and methods used in their included studies – and the lack of a clear definition of the term “pro-poor” – limit what other conclusions can be drawn. The reviewers say that before an infectious disease programme can be considered to be pro-poor, there should be hard evidence that there have been long-term health gains for the poor and vulnerable; this means establishing in advance the outcomes that will be measured when the programme is evaluated.

They go on to argue that improving access to treatment and prevention for the poor and vulnerable requires a thorough understanding of the socioeconomic and sociocultural dimensions, and that programmes will be most likely to succeed if they involve multisectoral approaches addressing environmental factors, health risks, health care and poverty alleviation.

More research is needed, especially as regards the pro-poor effectiveness of interventions for the neglected tropical diseases. However, the authors point out that a coherent framework for the evaluation of programme outcomes with a pro-poor focus has not yet been developed.

Other sources of information on pro-poor health care interventions