SOCIAL SERVICE IN GROUPS
DEVELOP A SOCIAL SERVICE FOR THE VULNERABLE GROUPS
INTRODUCTION
Assessing the health of vulnerable children in developing countries is an imperative goal of national
and international organizations, both because of the need to appropriately structure interventions
and because the health of children is a mirror on the health, social standing, and economic resources of their parents. Studies have established the relationship between malnutrition and death in Nigeria, and poor nutrition in the past was a leading cause of increased overall mortality. However, declines in child mortality in the region mean that measures of morbidity are more appropriate to understand the health of the population.
Morbidity measures: The mothers of these children were asked about chronic and acute
conditions suffered by their offspring during the past year and the past three months,
respectively. Chronic conditions surveyed were anemia, arthritis/rheumatism, broken bones,
cataracts, eye disease, asthma, other breathing problems, diabetes, urination pain, paralysis,
tuberculosis, gastric ulcer, edema, and “other” chronic illness. Mother’s reports of chronic
conditions included whether the condition caused difficulty in daily life, whether the child
received medicine for the condition, and whether the child saw a health care provider or stayed
in a hospital as a result. Acute conditions surveyed were headache, eye infection, toothache,
cough/fever/cold, vomiting/stomachache, fever with chills, watery diarrhea, loose stool with
mucus or blood, skin problems, accidents, excessive bleeding (girls), and “other” acute illnesses.
Mother’s reports of acute conditions included the number of days the child was sick and unable
to perform daily activities (school and work), the number and length of episodes, the date of the
last episode, and whether the child saw a health care provider.
For the purpose of this analysis, two dependent variables were constructed, one
classifying a child who experienced any acute symptoms during the past three months, and one
classifying a child who experienced any chronic symptoms during the past year. In addition,
acute diarrhea and dysentery were examined separately, given their prevalence in the region; the
results were identical to those obtained using “all acute illness,” and thus are not reported.
MEANIING OF VULNERABLE GROUPS
Vulnerable groups are relatively defined as the groups who find it hard to survive and who lack development opportunities due to being at a relative disadvantage in the economic, cultural, physical, intellectual, and other situations. The key to the understanding of vulnerable groups lies in determining the evaluation criteria and based on this certain evaluation criteria determining the relevant groups. Currently, the evaluation criteria are limited to the economical aspects. In other words, it is assumed that living with hardship results from a low level of income which is below the average. However, it is too limited if we rely solely on the economic criteria to determine vulnerable groups. Therefore, in order to define vulnerable groups in a systematic and scientific way, we need to include the following criteria:
m
Chronic Illness
Similar analyses attempted to predict chronic illness from the three proxy health
measures. Interestingly, only low weight-for-age predicts chronic illness, rather than low height-
or BMI-for-age as expected (these models are not shown, but demonstrate no significant
relationships). Contrary to expectations, underweight appears to predict chronic illnesses in this
population, a relationship that persists with controls for age, sex, parental education, income, and
MCH-FP program area residence, none of which are significant (see Table 8). However,
because of the strong increase in low weight, height, and BMI with age, we did not end the
investigation with these models.
Situational analysis
More than 10.6 million children under five years of age died in year 2000 IN South-East Asia,
over half of them caused by only five preventable communicable diseases. With 28% of all child
deaths annually occurring in South-East Asia, it is well known that 54% of diseases are linked to the
underlying factor of malnutrition (2). Two thirds of all malnutrition cases are associated with
inappropriate feeding practices in the first year of life; only 35% infants 0-4 months old are
exclusively breastfed while complementary feeding is inadequate and in most cases wrongly timed,
and not prepared safely. (3).
Though some improvement has been noted in the South-East Asia Region, almost half the
world’s 140 million underweight children – 65 million – live in South Asia alone (4). Prevalence of
xerophthalmia among children under-five is 0.53%, which is above the public health cut-off point.
Total Goitre Rate (TGR) and Urine Iodine Excretion (UIE) rates among the people indicate that
Iodine Deficiency Disorder (IDD) is still a big problem for countries in this Region and required a
strong commitment to realize the achievement of Universal Salt Iodization. Household consumption
of adequately iodized salt have to increase from the existing level of 67% to 90% to eliminate the
disorders cause by iodine deficiency.
Chronic energy malnutrition occurs among 38% of women of reproductive age and more than
50% of pregnant women are iron deficient. This risk factor makes not only the mother, but also the
neonates prone to increased morbidity and mortality during delivery and postpartum.
As a consequence of unhealthy diet and physical inactivity, 22 million children under five years
of age and 1 billion adults are overweight, leading to the prospect of 17 million people dying
prematurely each year from chronic diseases. Chronic diseases are responsible for 60% of all deaths
worldwide and 80% of these deaths occur in low and middle-income countries. In the SEA Region
alone, elimination of major risk factors could save over 8 million lives and result in an economic gain
of US$ 15 billion over the next 10 years (5 & 6). Though the evidence of overnutrition as a major risk
for serious diet related noncommunicable diseases is compelling, this remains a neglected public
health problem.
In ageing populations, both undernutrition and overnutrition are problems that need to be
tackled. Chronic noncommunicable diseases (NCD), and presence of high blood pressure, high blood
lipids and glucose intolerance have emerged in as many as 40% of the elderly who are from lowincome
groups. The number of instances of NCDs among the elderly in the SEA Region is expected
to double by 2025.
Ill health, either due to undernutrition or overnutrition in all age groups should be eliminated by
addressing determinants of malnutrition, which result in morbidity, intellectual productivity,
decreased life expectancy, and death of the population. Manifestations of nutritional disorders are
varied and seen in the lifecycle span of human beings. In order to design a or strengthen the nutrition
programme for a country, the magnitude of the problem in every phase of life from before birth to an
advanced age has to be taken into account. This is listed in Annex 1.
The two facets of nutrition-related problems – undernutrition and overnutrition –need to be
brought together under the spectrum of malnutrition. Nutritional deficiencies or overnutrition always
manifest themselves after a long time. Socio-economic determinants such as poverty, social exclusion,
low levels of education, behaviour and culture, political instability and continuing conflict
significantly contribute to malnutrition and related disorders.
The potential for synergies to achieve the MDGs for nutrition (reduce hunger and improve
nutrition status) incorporates multisectoral inputs such as improved agricultural practices, tariffs and
trade, reduction of women’s workload, better gender relations and intra-household decision-making.
The targets are to regulate food prices, raise family income and promote dietary diversity and food
security at the household level. Although effective interventions to prevent malnutrition (both
undernutrition and overnutrition) are known, appropriate counselling and nutrition care remain
unavailable, unused, inaccessible or of poor quality for many marginalized groups of the population.
The vision to achieve better nutrition for health and development, where people everywhere at
every age enjoy a high level of nutritional well-being free from all forms of hunger and malnutrition,
needs to be translated into action by involving all stakeholders, including family, community and their
broader social networks.
Strategic directions
Improve management in nutrition programme
Nutrition is a public health issue that has a strong correlation with related health programmes
which are maternal and newborn health, child and adolescent health, communicable and noncommunicable
diseases, environmental and occupational health, psychosocial development and
mental health. But nutrition is also a cross-sectored programme and involves, other than the health
sector, Planning (human development), Agriculture (food security), Industry and Trade (food
availability), Economy (purchasing power), Woman and Child Development (family empowerment),
Education (knowledge and skill), Manpower/Workforce (productivity) and Socio-culture (nutritional
behaviour). Nutrition programmes need to look beyond the health sector and must be taken as an
integrated approach for successful implementation.
As cross-disciplinary global commitments are involved, countries need to take responsibility for
translating their international commitments into national and local reality. This includes adopting
policies to create a socio-political environment suitable for the health system to respond to the
demands of the target population. A strong political will, adequate investment in the nutrition
programme and consistencies in implementing the strategies for the health system are indicators of
success in achieving the MDGs related to halving the number of underweight children and proportion
of population placed below the minimum level of dietary energy consumption.
Access to a well-functioning health care system is necessary to include nutrition interventions in
every lifecycle through a continuum of quality care starting from before pregnancy to an advanced
age of the population. In many countries, national capacity and resources (human, financial and
material) are still inadequate to ensure availability of and access to essential health services
particularly to those who are most vulnerable.
The following aspects need to be addressed in improving nutrition programme management:
Improve access to nutrition services
Though the technology for combating malnutrition is available, and effective interventions exist,
these are being resorted to rarely. Since the Alma Alta Declaration in 1978, nutrition services have
been made part of primary health care. The movement to conduct applied growth monitoring and
promotion of nutrition at the village level is worldwide. The GOBI-FF Movement (growth monitoring
and promotion, oral rehydration therapy, breastfeeding, immunization, family planning and female
participation) is an example. Some of the current trends in the progress of countries towards achieving
better nutritional status are encouraging while others seem to indicate that it will be difficult to meet
expected targets. Reduction of malnutrition rate could be achieved by scaling up coverage rates of key
nutrition services. The nutrition programme managers in the countries should review and assess
nutritional problems in their areas and their major causes. This can be used as a basis to design
effective programmes and include new services in order to extend interventions to those most difficult
to reach, not only geographically but more importantly, due to socio-economic and financial
constraints.
The essential package of nutrition services include growth monitoring and counselling on
growth faltering, promoting infant and young child feeding (breast-feeding and complementary
feeding), eliminating micronutrient malnutrition, home-based feeding practices, and
overweight/obesity prevention. The nutrition service package could be disaggregated by the target
group according to the lifecycle approach. Interventions for maternal and neonatal health before, and
at birth, includes women of reproductive age for targeting dietary advice, nutrition promotion for
adolescent eating patterns and sedentary lifestyle behaviour, and health promotion for improving
knowledge, attitudes and practices of mothers-to-be. Improving the nutritional status of teenagers
while delaying pregnancy could reduce risk factors that affect the health and survival chances of both
mother and child.
The nutrition programme, however, neglects large sections of the adult population, especially
males. In fact, male health should be prioritized since being breadwinners their nutritional and health
status will have an impact on productivity and family incomes. The need to adopt a healthy diet and
reduce consumption of tobacco and alcohol among adults should be featured in a national campaign.
Proposed nutrition programmes during the lifecycle that will fill the gaps in the existing programmes
are listed in Annex 2.
Developing community-based family nutrition improvement activities by empowering nonformal
village leaders is an effective way to bring the benefits of an applied programme to the needy.
Every village has to be served by trained health volunteers under regular supervision of nutrition
providers from the sub-district health centre.
Ensure the quality of nutrition care and improve logistics management
All populations in need of nutrition services should benefit from efficacious and cost-effective
interventions with quality facilities and timely and adequate provision of logistics being an essential
component. The government needs to ensure that affordable micronutrient supplements and logistics
reach the people who need them most.
Increasing the efficiency and responsiveness of the health system for providing adequate quality
services will automatically improve both coverage and compliance. This includes, for example,
effective nutrition management of health facilities, wider use of standardized guidelines, improved
supervision of nutrition and counselling services, a bigger role given to industrial government
companies in providing essential micronutrient supplements and other supplies on time (e.g., growth
charts, weighing scales, nutrition promotion packages, etc).
Strengthen assessment, monitoring and evaluation
Decision-makers and planners need reliable information on the cost-effectiveness and efficiency
of interventions. This information comes from recording and reporting of nutrition services which
need to be integrated into the existing health information system. To serve accurate information,
periodical monitoring of the coverage and quality of services has to be conducted and supervised by
the higher health authority.
Nutrition surveillance should be initiated to provide a system of targeting intervention to the
disadvantaged in a timely and usable fashion. All information has to feed into the policy debate which
decides on capacity to meet health and nutrition programme needs, select correct strategies, monitor
performance and manage change. Feedback on the results, of monitoring and evaluation are necessary
to ensure that this information contributes towards identifying specific nutrition requirements and
provision of direct services to the areas of greatest need.
Extra government health spending and improved health care financing system
Poverty is always associated with inequitable access to health services. Though facilities are
built to extend to the remote sub-districts, transportation costs from the village to health facilities pose
a major problem. The government, therefore, has to ensure that the social safety net for the poor is
firmly in place.
A minimum of US$30-40 per capita is needed annually to finance an essential health services
package (7). Increased government spending on health is only a part of the answer to reach the MDGs
since it also needs to be targeted geographically with specific programmes for specific population
groups to remove bottlenecks (8, 9). To reach the MDGs target, a minimum of five percentage points
would need to be added to the rate of growth of the government health share of GDP. That would take
the projected share of GDP spending on government health programmes to 3.7% in 2015 (10).
The development of various types of health care financing mechanisms is likely to help achieve
the goal of equity, better health and responsiveness and fair financing. Many other forms of risk
pooling schemes such as community-based trust funds could be introduced so that health risks of the
poor are adequately protected (11). To improve coverage of nutrition care and counselling, severely
malnourished children and pregnant mothers with complications have to be brought under the cover
of financing schemes. Social health care financing systems should mainly provide health and nutrition
services free of charge, and a subsidy for transporting the needy from remote areas to the nearest
health facility.
INTRODUCTION
Assessing the health of vulnerable children in developing countries is an imperative goal of national
and international organizations, both because of the need to appropriately structure interventions
and because the health of children is a mirror on the health, social standing, and economic resources of their parents. Studies have established the relationship between malnutrition and death in Nigeria, and poor nutrition in the past was a leading cause of increased overall mortality. However, declines in child mortality in the region mean that measures of morbidity are more appropriate to understand the health of the population.
Morbidity measures: The mothers of these children were asked about chronic and acute
conditions suffered by their offspring during the past year and the past three months,
respectively. Chronic conditions surveyed were anemia, arthritis/rheumatism, broken bones,
cataracts, eye disease, asthma, other breathing problems, diabetes, urination pain, paralysis,
tuberculosis, gastric ulcer, edema, and “other” chronic illness. Mother’s reports of chronic
conditions included whether the condition caused difficulty in daily life, whether the child
received medicine for the condition, and whether the child saw a health care provider or stayed
in a hospital as a result. Acute conditions surveyed were headache, eye infection, toothache,
cough/fever/cold, vomiting/stomachache, fever with chills, watery diarrhea, loose stool with
mucus or blood, skin problems, accidents, excessive bleeding (girls), and “other” acute illnesses.
Mother’s reports of acute conditions included the number of days the child was sick and unable
to perform daily activities (school and work), the number and length of episodes, the date of the
last episode, and whether the child saw a health care provider.
For the purpose of this analysis, two dependent variables were constructed, one
classifying a child who experienced any acute symptoms during the past three months, and one
classifying a child who experienced any chronic symptoms during the past year. In addition,
acute diarrhea and dysentery were examined separately, given their prevalence in the region; the
results were identical to those obtained using “all acute illness,” and thus are not reported.
MEANIING OF VULNERABLE GROUPS
Vulnerable groups are relatively defined as the groups who find it hard to survive and who lack development opportunities due to being at a relative disadvantage in the economic, cultural, physical, intellectual, and other situations. The key to the understanding of vulnerable groups lies in determining the evaluation criteria and based on this certain evaluation criteria determining the relevant groups. Currently, the evaluation criteria are limited to the economical aspects. In other words, it is assumed that living with hardship results from a low level of income which is below the average. However, it is too limited if we rely solely on the economic criteria to determine vulnerable groups. Therefore, in order to define vulnerable groups in a systematic and scientific way, we need to include the following criteria:
m
Chronic Illness
Similar analyses attempted to predict chronic illness from the three proxy health
measures. Interestingly, only low weight-for-age predicts chronic illness, rather than low height-
or BMI-for-age as expected (these models are not shown, but demonstrate no significant
relationships). Contrary to expectations, underweight appears to predict chronic illnesses in this
population, a relationship that persists with controls for age, sex, parental education, income, and
MCH-FP program area residence, none of which are significant (see Table 8). However,
because of the strong increase in low weight, height, and BMI with age, we did not end the
investigation with these models.
Situational analysis
More than 10.6 million children under five years of age died in year 2000 IN South-East Asia,
over half of them caused by only five preventable communicable diseases. With 28% of all child
deaths annually occurring in South-East Asia, it is well known that 54% of diseases are linked to the
underlying factor of malnutrition (2). Two thirds of all malnutrition cases are associated with
inappropriate feeding practices in the first year of life; only 35% infants 0-4 months old are
exclusively breastfed while complementary feeding is inadequate and in most cases wrongly timed,
and not prepared safely. (3).
Though some improvement has been noted in the South-East Asia Region, almost half the
world’s 140 million underweight children – 65 million – live in South Asia alone (4). Prevalence of
xerophthalmia among children under-five is 0.53%, which is above the public health cut-off point.
Total Goitre Rate (TGR) and Urine Iodine Excretion (UIE) rates among the people indicate that
Iodine Deficiency Disorder (IDD) is still a big problem for countries in this Region and required a
strong commitment to realize the achievement of Universal Salt Iodization. Household consumption
of adequately iodized salt have to increase from the existing level of 67% to 90% to eliminate the
disorders cause by iodine deficiency.
Chronic energy malnutrition occurs among 38% of women of reproductive age and more than
50% of pregnant women are iron deficient. This risk factor makes not only the mother, but also the
neonates prone to increased morbidity and mortality during delivery and postpartum.
As a consequence of unhealthy diet and physical inactivity, 22 million children under five years
of age and 1 billion adults are overweight, leading to the prospect of 17 million people dying
prematurely each year from chronic diseases. Chronic diseases are responsible for 60% of all deaths
worldwide and 80% of these deaths occur in low and middle-income countries. In the SEA Region
alone, elimination of major risk factors could save over 8 million lives and result in an economic gain
of US$ 15 billion over the next 10 years (5 & 6). Though the evidence of overnutrition as a major risk
for serious diet related noncommunicable diseases is compelling, this remains a neglected public
health problem.
In ageing populations, both undernutrition and overnutrition are problems that need to be
tackled. Chronic noncommunicable diseases (NCD), and presence of high blood pressure, high blood
lipids and glucose intolerance have emerged in as many as 40% of the elderly who are from lowincome
groups. The number of instances of NCDs among the elderly in the SEA Region is expected
to double by 2025.
Ill health, either due to undernutrition or overnutrition in all age groups should be eliminated by
addressing determinants of malnutrition, which result in morbidity, intellectual productivity,
decreased life expectancy, and death of the population. Manifestations of nutritional disorders are
varied and seen in the lifecycle span of human beings. In order to design a or strengthen the nutrition
programme for a country, the magnitude of the problem in every phase of life from before birth to an
advanced age has to be taken into account. This is listed in Annex 1.
The two facets of nutrition-related problems – undernutrition and overnutrition –need to be
brought together under the spectrum of malnutrition. Nutritional deficiencies or overnutrition always
manifest themselves after a long time. Socio-economic determinants such as poverty, social exclusion,
low levels of education, behaviour and culture, political instability and continuing conflict
significantly contribute to malnutrition and related disorders.
The potential for synergies to achieve the MDGs for nutrition (reduce hunger and improve
nutrition status) incorporates multisectoral inputs such as improved agricultural practices, tariffs and
trade, reduction of women’s workload, better gender relations and intra-household decision-making.
The targets are to regulate food prices, raise family income and promote dietary diversity and food
security at the household level. Although effective interventions to prevent malnutrition (both
undernutrition and overnutrition) are known, appropriate counselling and nutrition care remain
unavailable, unused, inaccessible or of poor quality for many marginalized groups of the population.
The vision to achieve better nutrition for health and development, where people everywhere at
every age enjoy a high level of nutritional well-being free from all forms of hunger and malnutrition,
needs to be translated into action by involving all stakeholders, including family, community and their
broader social networks.
Strategic directions
Improve management in nutrition programme
Nutrition is a public health issue that has a strong correlation with related health programmes
which are maternal and newborn health, child and adolescent health, communicable and noncommunicable
diseases, environmental and occupational health, psychosocial development and
mental health. But nutrition is also a cross-sectored programme and involves, other than the health
sector, Planning (human development), Agriculture (food security), Industry and Trade (food
availability), Economy (purchasing power), Woman and Child Development (family empowerment),
Education (knowledge and skill), Manpower/Workforce (productivity) and Socio-culture (nutritional
behaviour). Nutrition programmes need to look beyond the health sector and must be taken as an
integrated approach for successful implementation.
As cross-disciplinary global commitments are involved, countries need to take responsibility for
translating their international commitments into national and local reality. This includes adopting
policies to create a socio-political environment suitable for the health system to respond to the
demands of the target population. A strong political will, adequate investment in the nutrition
programme and consistencies in implementing the strategies for the health system are indicators of
success in achieving the MDGs related to halving the number of underweight children and proportion
of population placed below the minimum level of dietary energy consumption.
Access to a well-functioning health care system is necessary to include nutrition interventions in
every lifecycle through a continuum of quality care starting from before pregnancy to an advanced
age of the population. In many countries, national capacity and resources (human, financial and
material) are still inadequate to ensure availability of and access to essential health services
particularly to those who are most vulnerable.
The following aspects need to be addressed in improving nutrition programme management:
Improve access to nutrition services
Though the technology for combating malnutrition is available, and effective interventions exist,
these are being resorted to rarely. Since the Alma Alta Declaration in 1978, nutrition services have
been made part of primary health care. The movement to conduct applied growth monitoring and
promotion of nutrition at the village level is worldwide. The GOBI-FF Movement (growth monitoring
and promotion, oral rehydration therapy, breastfeeding, immunization, family planning and female
participation) is an example. Some of the current trends in the progress of countries towards achieving
better nutritional status are encouraging while others seem to indicate that it will be difficult to meet
expected targets. Reduction of malnutrition rate could be achieved by scaling up coverage rates of key
nutrition services. The nutrition programme managers in the countries should review and assess
nutritional problems in their areas and their major causes. This can be used as a basis to design
effective programmes and include new services in order to extend interventions to those most difficult
to reach, not only geographically but more importantly, due to socio-economic and financial
constraints.
The essential package of nutrition services include growth monitoring and counselling on
growth faltering, promoting infant and young child feeding (breast-feeding and complementary
feeding), eliminating micronutrient malnutrition, home-based feeding practices, and
overweight/obesity prevention. The nutrition service package could be disaggregated by the target
group according to the lifecycle approach. Interventions for maternal and neonatal health before, and
at birth, includes women of reproductive age for targeting dietary advice, nutrition promotion for
adolescent eating patterns and sedentary lifestyle behaviour, and health promotion for improving
knowledge, attitudes and practices of mothers-to-be. Improving the nutritional status of teenagers
while delaying pregnancy could reduce risk factors that affect the health and survival chances of both
mother and child.
The nutrition programme, however, neglects large sections of the adult population, especially
males. In fact, male health should be prioritized since being breadwinners their nutritional and health
status will have an impact on productivity and family incomes. The need to adopt a healthy diet and
reduce consumption of tobacco and alcohol among adults should be featured in a national campaign.
Proposed nutrition programmes during the lifecycle that will fill the gaps in the existing programmes
are listed in Annex 2.
Developing community-based family nutrition improvement activities by empowering nonformal
village leaders is an effective way to bring the benefits of an applied programme to the needy.
Every village has to be served by trained health volunteers under regular supervision of nutrition
providers from the sub-district health centre.
Ensure the quality of nutrition care and improve logistics management
All populations in need of nutrition services should benefit from efficacious and cost-effective
interventions with quality facilities and timely and adequate provision of logistics being an essential
component. The government needs to ensure that affordable micronutrient supplements and logistics
reach the people who need them most.
Increasing the efficiency and responsiveness of the health system for providing adequate quality
services will automatically improve both coverage and compliance. This includes, for example,
effective nutrition management of health facilities, wider use of standardized guidelines, improved
supervision of nutrition and counselling services, a bigger role given to industrial government
companies in providing essential micronutrient supplements and other supplies on time (e.g., growth
charts, weighing scales, nutrition promotion packages, etc).
Strengthen assessment, monitoring and evaluation
Decision-makers and planners need reliable information on the cost-effectiveness and efficiency
of interventions. This information comes from recording and reporting of nutrition services which
need to be integrated into the existing health information system. To serve accurate information,
periodical monitoring of the coverage and quality of services has to be conducted and supervised by
the higher health authority.
Nutrition surveillance should be initiated to provide a system of targeting intervention to the
disadvantaged in a timely and usable fashion. All information has to feed into the policy debate which
decides on capacity to meet health and nutrition programme needs, select correct strategies, monitor
performance and manage change. Feedback on the results, of monitoring and evaluation are necessary
to ensure that this information contributes towards identifying specific nutrition requirements and
provision of direct services to the areas of greatest need.
Extra government health spending and improved health care financing system
Poverty is always associated with inequitable access to health services. Though facilities are
built to extend to the remote sub-districts, transportation costs from the village to health facilities pose
a major problem. The government, therefore, has to ensure that the social safety net for the poor is
firmly in place.
A minimum of US$30-40 per capita is needed annually to finance an essential health services
package (7). Increased government spending on health is only a part of the answer to reach the MDGs
since it also needs to be targeted geographically with specific programmes for specific population
groups to remove bottlenecks (8, 9). To reach the MDGs target, a minimum of five percentage points
would need to be added to the rate of growth of the government health share of GDP. That would take
the projected share of GDP spending on government health programmes to 3.7% in 2015 (10).
The development of various types of health care financing mechanisms is likely to help achieve
the goal of equity, better health and responsiveness and fair financing. Many other forms of risk
pooling schemes such as community-based trust funds could be introduced so that health risks of the
poor are adequately protected (11). To improve coverage of nutrition care and counselling, severely
malnourished children and pregnant mothers with complications have to be brought under the cover
of financing schemes. Social health care financing systems should mainly provide health and nutrition
services free of charge, and a subsidy for transporting the needy from remote areas to the nearest
health facility.