Reaching the poor: a challenge for nurses


In 2008, we shall pass the halfway point for achieving the United Nations (UN) Millennium Development Goals by 2015 (UN 2000). So how we are progressing? Not very well, according to a new World Bank report on inequities in health.

A recent publication by the Health, Nutrition and Population Section (HNP) of The World Bank, in collaboration with the Dutch and Swedish Governments, provides probably the most comprehensive report yet produced on Socio-Economic Differences in HNP within Developing Countries (Gwatkin et al. 2007). The Overview and 56 individual country reports may be obtained from the HNP Advisory Service at (For further information about the report and a list of countries, see page 11.)

The findings based on fieldwork and data analysis of comprehensive surveys in 56 middle and low-income countries are not encouraging. As such, they provide essential reading for nurses worldwide. Two major conclusions emerge from the mass of data:

  • • the health of the poor is notably worse than that of people who are better off; and;
  • • the poor use health services less frequently, have less adequate health-related behaviours, and are disadvantaged with respect to other determinants of health status.

My reasons for choosing this major report on inequities in health as the subject for an editorial is not to provide a stick to beat ourselves with over the failures of health systems. It is to encourage nurses to understand both from practice and research perspectives just how complicated are the assessments of health inequalities, and how carefully we need to construct our intervention and evaluation methods in order to assess any policies intended to reduce them.

First, health inequality has several overlapping, theoretical underpinnings, and in terms of health policies, each will also determine the aims and criteria for success (Robinson & Elkan 1996). Second, this latest HNP series is based on fundamental work carried out in order to measure health inequality's economic dimension. The resultant wealth, or asset, index is a valid standard, which nurses working in the less developed world could use in their assessments of planned interventions. This would result in studies whose outcomes were genuinely comparable, something nursing research on reaching the poor urgently needs if it is to progress. Third, despite considerable variation among countries with regard to any particular service, with the exception of breast-feeding, the poor gain less from Primary Care than do the better off. Almost 30 years since the launch of WHO's Health For All and UNICEF's Child Survival Revolution, this finding must challenge nurses to ask the following questions:

  • • How are we identifying and prioritising the poorest people to receive our interventions?
  • • How are we tailoring those interventions to meet the needs of the poorest in our societies? and;
  • • How scientifically are we evaluating the outcomes?

With seven years to go until 2015, these are questions that nurses need to address with some urgency.