Very poor people are often considered ignorant and even incapable of thinking, because they have had no opportunity to gain skill in expression through education. The experience of contempt and exclusion is deep among the poorest, whether they live in rich or poor countries, and it often prevents them from participating in social programs. This note provides a summary of a study on access to health care conducted by the International Movement ATD Fourth World in Madagascar, with the aim to outline the organization's approach to reaching the very poor and building projects in close partnership with them.Extreme Poverty, Health Care, Community Development, Madagascar

Blanchard, Caroline

Godinot, Xavier

Laureau, Chantal

Wodon, Quentin

English

Research Papers in Economics

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

Learning from the Extreme Poor: Participatory Approaches to Fostering Child Health in Madagascar

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