Informing poor in India boosts public service use

October 22, 2007

Simply informing the poor about government-provided health, educational, and social services they are entitled to could empower them to take greater advantage of free or low-cost public services, a study in India suggests. The finding, reported in this week's 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, the 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 they are entitled to 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 they are entitled to. "Our hope was that if village residents knew what their rights were, they would be more likely to demand them from service providers," says Goyal.

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 to be available. 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 the community is entitled to 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 goverment meetings where elected village representatives decide how to use government funds for the development of the village.

Roughly half of 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 the meetings and those without. Village clusters that held the educational 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-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," says Goyal.

He points out that the informational program cost only $4000, or about 22 cents per household. Disseminating the same information by radio and newspapers could lower costs even more.

This strategy could be useful in other similarly-challenged countries. Though the problems aren't as prevalent in the United States, he says, "This type of intervention would still be useful to explore here."
The study was funded by Sahbhagi Shikshan Kendra (a non-governmental organization based in Uttar Pradesh) and the World Bank.

Other researchers involved in the study include David Levine, M.D., Sc.D., of The Johns Hopkins School of Medicine, Priyanka Pandey, Ph.D., and Michelle Riboud, Ph.D., both of the World Bank, and Ashwini R. Sehgal, M.D., of Case Western Reserve University.

Johns Hopkins Medicine

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