Simply informing the poor about government-provided
health, educational and social services to
which they are entitled could empower them to take greater
advantage of free or low-cost public
services, a study in India suggests. The finding, reported
in the Oct. 24 issue of the Journal of the
American Medical Association, could be an overlooked,
relatively easy way to boost health and well-
being in developing countries around the world.
The study was conducted by researchers at the Johns
Hopkins School of Medicine, World Bank
and Case Western Reserve University.
In India and many other less-developed countries,
federal and local governments provide a
variety of public services in areas of health and
education; however, these services are often
inadequately provided. Why services do not reach the poor
has been unclear, says the study's senior
researcher, Madhav Goyal, a general internal
medicine fellow at the Johns Hopkins School of
Medicine.
Previous work suggests that the answer relates to a
combination of factors. Local communities
may not be able to hold public service providers such as
health care workers and teachers accountable.
This lack of accountability may in part be because
communities are poorly informed of the services to
which they are entitled as well as of the legal controls
they have over public services.
To test their ideas, research team members looked into
the usefulness of educating residents
of one of India's poorest states on the services to which
they are entitled.
"Our hope was that if village residents knew what
their rights were, they would be more likely
to demand them from service providers," Goyal said.
The team's efforts centered on Uttar Pradesh, a state
where one-third of the population
subsists on less than $90 per person each year. Less than
60 percent of the population is literate, so
the team needed to craft an outreach plan that would inform
people who couldn't read.
The researchers first determined which public services
are mandated. They then randomly
selected 105 village clusters — small groups of
adjacent villages with a single head and council members.
The team interviewed households in each cluster, taking a
baseline reading of residents' knowledge of
public benefits and how often household members accessed
these services.
Then Goyal and colleagues staged town meetings in some
villages, playing a recorded message
about public services to which the community is entitled
and what legal controls the community has in
obtaining these. Villagers could ask questions. Topics
included prenatal and delivery care for pregnant
women, vaccines for children, public schools and the right
to participate in village government
meetings where elected village representatives decide how
to use government funds for the
development of the village.
Roughly half the randomly selected villages held these
informational town meetings. Others
received no additional education about public services.
One year later, a second survey of households in the
village clusters measured results. Blinded
researchers conducted the surveys.
Significant differences existed between village
clusters with educational meetings and those
without. Clusters that held the meetings reported 30
percent more prenatal exams, 24 percent more
prenatal supplementations, 27 percent more tetanus
vaccinations and 25 percent more infant
vaccinations. School fees that were frequently illegally
inflated to 28 rupees or more dropped down to
18 rupees on average. Additionally, residents reported
holding 21 percent more village council
meetings.
"With this minimal intervention — holding these
informational meetings — people reported better
receipt of services they are entitled to," Goyal said.
He points out that the informational program cost only
$4,000, or about 22 cents per
household, and that disseminating the same information by
radio and newspapers could even lower
costs.
This strategy could be useful in other similarly
challenged countries. Though the problems
aren't as prevalent in the United States, "this type of
intervention would still be useful to explore
here," he said.
The study was funded by Sahbhagi Shikshan Kendra, a
nongovernmental organization based in
Uttar Pradesh; and the World Bank.
Other researchers involved in the study are David
Levine, of the Johns Hopkins School of
Medicine; Priyanka Pandey and Michelle Riboud, both of the
World Bank; and Ashwini R. Sehgal, of
Case Western Reserve University.
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