40813 Health, Nutrition and Population 277 August 2007 Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Operations Results and Learning Unit on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Learning from the Extreme Poor: Participatory Approaches to Fostering Child Health in Madagascar by Caroline Blanchard, Xavier Godinot, Chantal Laureau and Quentin Wodon D efinitions of poverty in people listen to them. developing countries used "We impose outside interpreta- by most development organiza- tions on them that prevent them tions focus on household income from reflecting on their own or consumption that falls below a lives," suggests Joseph given threshold, such as one Wresinski, who founded the dollar per capita per day, and on International Movement ATD other quantified indicators. Fourth World, which focuses on While such definitions have the the very poor. ATD Fourth World merit of providing a standard by has been persistent over the last which to measure progress, the 50 years in its effort to engage very poor use quite different political leaders the world over, terms and ideas to communicate as well as international develop- what extreme poverty means to ment institutions (including the them. World Bank), in the fight against Extreme poverty results not extreme poverty. ATD Fourth only from insufficient financial World is determined that these resources but from a lack of institutions should truly recog- basic security in many different nize the needs of people in areas, including education, situation of extreme poverty, but employment, housing, and even more that they should health care, as well as social listen directly to their voices. exclusion. Left to the side in ATD would also like to see its civic, social, and cultural life, spirit of respect for the poor and in political decision making, spread more widely, so that top- very poor people are often consid- down, hasty, and untested ap- ered ignorant and even incapable proaches and development Findings of thinking, because they have projects do not further disrupt the had no opportunity to gain skill fragile and tenuous lives of poor in expression through education. communities. Theirs is a call for The experience of contempt and an approach that builds on the exclusion--severely attacking consent and measured reflection self-confidence--is deep among of those who poverty programs the poorest, whether they live in purport to target. rich or poor countries. Very few ATD Fourth World's Approach to Fourth World, which over time that strengthened parents' Learning from people mired in took root in many countries capabilities allowed new paths to extreme poverty across the world. Together with a open based on greater under- Dutch diplomat, he also founded standing and mutual respect. Joseph Wresinski, a Catholic an Office of Social Research, The case study starts in 1991. priest, founded ATD Fourth World which later became the research At that time, the health situation in France in 1957. A grassroots and training institute for his in the neighborhood, known as advocacy organization, ATD movement. This passionate and Antohomadinika, was worrisome. Fourth World inspired the UN's principled man, trained in the Infant mortality was very high annual World Day to Overcome harsh school of destitution and and life expectancy short. From Extreme Poverty (which falls on exclusion, became a respected its first few months in October 17). The organization spokesman of the poorest at Antananarivo (Madagascar's runs projects that engage deeply national and international levels. capital city), the ATD Fourth and directly with the very poor in World team was keenly aware of 28 developed and developing Health and Living Conditions in the fragile health of young chil- countries. Antananarivo, Madagascar dren. Over the years, by immers- Wresinski and ATD Fourth ing themselves in the neighbor- World's leaders have advocated for A case study helps elucidate hood, they discovered the chasm investing in the knowledge of the ATD Fourth World's approach. separating Antohomadinika's very poor since the organization The setting is a neighborhood inhabitants from the medical was founded. In a 1980 speech at with some 6,000 inhabitants in services that were supposed to UNICEF headquarters in Geneva, Antananarivo, Madagascar-- help. Wresinski articulated his vision, precarious and densely populated, Malagasy doctors are trained which still drives ATD Fourth with shabby dwellings, a few according to Western methods: World today. He started by affirm- drinking fountains, no toilets, they search for signs that support ing that everyone involved in and flooding during the rainy a diagnosis of disease in an development projects--including season that renders hygiene organ. This approach, which those living in extreme poverty, almost nonexistent. Parents have prevails worldwide, rarely consid- activists, and researchers--is a unstable jobs in the informal ers a patient's background, thinking human being with goals. economy, but nevertheless try to relationships, or environment, He contends that programs will be provide their children with an and creates a certain disdain effective only if they respect the education using a surprising toward traditional healing. The integrity of all three parties: amount of inventiveness and inhabitants of Antohomadinika, thorough understanding must energy. on the other hand, have tradi- always precede specific concepts In 1991 ATD Fourth World, tional beliefs that give meaning and methods. This fundamental together with neighborhood to each event and gesture. These and original lesson in epistemol- parents, launched a two-part contrasting views of illness, ogy, methodology, and ethics has program to promote health care together with a mutual lack of wide applicability for efforts to (which ended up lasting 10 years) understanding, explained the fight poverty. and knowledge sharing (which is fear that inhabitants felt when Wresinski himself experienced ongoing). At first, relations facing the modern medical world, living in extreme poverty, endur- between the inhabitants and and the sometimes humiliating ing it as a child born in France to health care providers reflected reactions of competent doctors. migrant parents. He later lived as fear and lack of understanding, Although parents were atten- a priest with the inhabitants of a with inhabitants resorting to tive toward their children, this shantytown close to Paris for 10 ancestral knowledge of tradi- was not immediately apparent to years, until all of them were tional medicine, and health care the medical staff. For example, offered new housing. With these staff reacting mostly according to mothers traditionally were afraid inhabitants, he founded the the norms of Western medicine. that a newborn would get a cold International Movement ATD However, several years of work stomach, and therefore preferred longer meet the demand. In 2003 is often secondary to family not to undress the baby. This 10 adults from the their Fourth unity. For example, a mother obviously contradicts rules of World, November 2006. cannot be hospitalized without hygiene that stress the impor- The ATD Fourth World team risking the death of a tance of bathing newborns. These noticed the overwhelming appeal breastfeeding child, who could not team decided to incorporate of books among the children and be cared for if the two were health into all its cultural activi- their parents. One day in October separated harshly. The ATD ties. This stepped-up work in- 1997, some mothers asked the Fourth World team observed, cluded larger meetings in two coordinators of the street library "parents often prefer keeping the small courtyards. Volunteers if they could borrow books to read family together to healing a would start these meetings by to their children at home. Nine child." In any case, the child may inviting all participants to wash parents soon started to borrow not be cured, and if he is it won't their hands, giving them a books, and four years later some last if the family goes through chance to exchange news and 340 youngsters and adults had particularly hard times." "Health perhaps invite the volunteers to registered for this service, and is the balance between a person, visit sick people at their homes. the coordination team could no his environment, and the com- A coordinator would then tell a longer meet the demand. In 2003 munity in which he lives. Illness story. After the story, volunteers 10 adults from the neighborhood upsets this balance." Health also presented simple educational and hired for this task built a library depends on community solidarity: development games to the moth- on donated land. adults can be hospitalized only if ers, and invited them to play with To complement the activities neighbors agree to look after their last-born child for the rest of in the small courtyards, the ATD their children, and to offer finan- the session. This made the Fourth World team organized a cial support. Improving hygiene mothers their children's first systematic follow-up of children in a neighborhood therefore teacher, and they felt at greater born in 1995 and early 1996. requires a change in attitude on ease in asking questions when Mothers began to create a devel- everyone's part. they saw themselves in this role. opment book for their children, Lack of understanding between The informal discussions also recording key moments at the medical staff and neighborhood allowed the women to learn start of life as well as their parents as well as fear had gradually more about their progress. Some mothers also prompted parents to put off a bodies, the nutritional value of recorded their hopes for each hospital visit as long as possible. food, and family planning. A child: "I would like you to learn to As trust became firmly estab- street library and a health pro- read and write, and to talk about lished and parents grew accus- gram, as well as home visits, how we should talk." Others tomed to speaking about health complemented these moments of explained their view of educa- and cultural practices, the ATD leisure between mothers and tion: "The aim of parents is to Fourth World team invited moth- their young children. see their children succeed in ers to visit health care centers The ATD Fourth World team life." "We encourage you so that around Antohomadinika, to meet noticed the overwhelming appeal you learn manners and know the staff and learn about the care of books among the children and how to write." "When he does they offered. The mothers thus their parents. One day in October something naughty, we give him discovered facilities they had not 1997, some mothers asked the a good telling off." In 1997, 26 known existed, like the Isotry coordinators of the street library women completed a development dispensary, Tsaralalana if they could borrow books to read book for a child. children's hospital, and the Marie to their children at home. Nine These books helped deepen Stopes international dispensary. parents soon started to borrow discussions between team ATD Fourth World also invited books, and four years later some members and the mothers on health professionals, mostly from 340 youngsters and adults had cultural practices. In the life of Befelatanana Hospital, to meet registered for this service, and the least-favored families, health with neighborhood mothers to the coordination team could no learn about their living condi- worlds. benefit. Daily survival requires tions. These professionals came Inhabitants are very proud of all their energy and attention, to realize how expensive a hospi- the book, and it has served as a and, perhaps even more sig- tal stay can be for poor people, starting point for conversations nificant, they often find it too beyond formal fees, as people between the neighborhood and shameful, painful, and terrify- need to spend time traveling to institutions. "This book aims to ing to take advantage of ser- the facility and the time they be an invitation for health care vices--especially those that spend there is time they when professionals to dare meet very address only their deprivations they cannot work. Precarious poor families.... The book says rather than their aspirations. living conditions also present a that such a meeting is possible Indeed, the projects that are barrier for specific treatments. and that everyone comes out on the most successful in reach- During these meetings, the top if we heed the concerns of ing the poorest tend to tap the mothers dared to talk others: if both professionals and aspirations they carry deep unashamedly about resorting to parents look for a better future inside but often have difficulty traditional methods--something for their children together, expressing. they would never have done parents could learn from the Many activities designed to inside a hospital--while the professionals and the profession- reduce poverty fail to reach the professionals saw women who als, having learned why the very disadvantaged people, who appeared frightened and parents are afraid, could cure are often so excluded that they ashamed in a hospital in a their children better." Funding seem beyond reach. This different light. provided by the World Bank exclusion also means that Few books have been written in through Madagascar's Health outsiders have difficulty Malagasy, and practically none on Ministry financed the printing of understanding their situation early childhood. The idea there- 200 copies of the book in 2002. By and efforts to emerge from fore arose to produce a book that showing how much parents love poverty. To acquire in-depth would help answer the questions their children, think about their knowledge of their aspirations parents ask most often. The book education, and expend energy on and build projects with them, could also illustrate the inven- their behalf, the book helped outsiders need tools, commit- tiveness of parents who confront change the reputation of a ment, and proximity. At the multiple challenges in educating neighborhood that was all too same time, people in situa- their children, and help smooth often regarded in negative terms. tion of chronic poverty need a discussions with health care clear understanding of the professionals. The book was Lessons for Other Programs intentions of those who want to published in May 2000 under the help them. title Sarobidy Ny Silaky Ny Aina, A seminar on extreme poverty The Madagascar and other which means Our Children Are a at the World Bank on October 19, case studies have implications Treasure. At first seen as a 2005, highlighted lessons from for grassroots organizations, simple collection of parents' the Madagascar case as well as governments, and even inter- words, the book later came to other case studies. A key conclu- national financial organiza- include information from moth- sion was that development tions working to eradicate ers' child development books. projects should not only take extreme poverty. Health care professionals helped people mired in extreme poverty First, working with people correct information they consid- into account but make them the trapped in extreme poverty ered wrong, and highlighted what highest priority, because they requires a long-term process, not seemed important to the develop- are least able to improve their a one-shot intervention. Reach- ment and health of young daily lives without the help of ing them requires a signifi- Malagasys. This work helped others. However, numerous cant human investment, not create a common language obstacles prevent them from only by outsiders but also by between the two very different participating in projects and themselves. Institutions must services designed for their make it clear from the beginning Making discussion and sharing Madagascar. The note was that partnering with them does possible among them thus depends prepared for a book by Katherine not mean entering into a short- on creating the conditions of Marshall and Marisa Van Saanen term agreement. Community equality where everybody's voice is to be published in 2007: Develop- mobilization often begins with listened to1. This implies humility ment and Faith: When Mind, finding the local groups that may from the better off, courage from Heart, and Soul Work Together, exist out of sight and focal places the worst off, and a constant World Bank, Washington, DC. such as community centers and monitoring by the mediators who The authors are grateful for the schools. From then on the build- bring them together. At the project inputs provided by Katherine ing process can continue. level, agents need to develop Marshall and Marisa Van Saanen. Second, programs that attack indicators of transformation of the extreme poverty should build a new social relations that hinder the Footnotes: social contract that allows those capacity of the most disadvantaged 1 These conditions are described who endure it (and other excluded to move out of poverty. One ap- in the Guidelines for the Crossroads of people) to take an active role in proach is to require projects to Knowledge and Practices and How to revamping the institutions that meet pre-established benchmarks Apply Them to People Living in Situa- redistribute assets and control before moving to the next level of tions of Poverty and Social Exclusion, decision making. Programs and investment. Research and Training Institute, projects will not work if people Overall, people mired in extreme International Movement ATD Fourth trapped in chronic poverty do not poverty must not only be reached World, November 2006. participate. Just as outsiders but also met as equals in dignity, require training, so do they, so deserving the respect and the that they can build their own human rights they are lacking expertise and share it with and longing for. Providing them others. This requires building with this respect and these rights their capacity to transform their is an undertaking that will trans- existing knowledge into a power- form both the excluders and the ful creative force that will break excluded, empowering the latter. down their dependence and allow Projects aiming to fight extreme them to construct new social poverty might be evaluated on a relations among themselves and very simple question: Has this with others. project allowed those who endure Third, this approach requires a it to advance toward greater new relationship between people freedom, pride and responsibility trapped in extreme poverty and rather than remaining in a cycle external agents, including govern- of deprivation and dependence? ment officials and civil society volunteers. This new relationship This note was prepared by should derive from a process of Caroline Blanchard, Xavier Godinot, mutual transformation, where each Chantal Laureau, and Quentin agent strives to share his own Wodon. It is based on a book edited knowledge and to learn from by Xavier Godinot and Quentin others. These agents must gener- Wodon in 2006: Participatory ate knowledge that will help Approaches to Attacking Ex- individuals, communities and treme Poverty: Case Studies Led institutions transform the reality by the International Movement in which they live. Yet these ATD Fourth World, World Bank agents occupy very unequal Working Paper No. 77, Washington, positions in society. DC, which includes a case study on