Leave no one behind, please!

The concept of ‘marginalization’ and ‘social exclusion’ is ‘highly depending on the historical and socio-economical context of a society.’ Briefly, ‘marginalizaion’ is ‘a process, originating from lack of awareness or negative attitudes of the larger society, by which certain population groups are denied access to resources and services essential for living a decent life’ and ‘social exclusion’ is ‘a process that involves the systematic denial of entitlements to resources and services...on the basis of  ethnicity, race, religion, sexual orientation, caste, descent, gender, age, disability, HIV status, migrant status or where they live.’

The underlying causes for marginalization and social exclusion include racism, extreme poverty, caste-based social system and associated stigma, migration (e.g., rural to urban migration, landing in pavements or slums), weak and  poorly-resourced and inefficient health systems failing to reach these populations, and lack of understanding and respect for human rights. Like the underlying causes, the process of margnalisation/social exclusion is also varied. The process involve structural barriers to education, employment, and land and other resources;  patriarchal attitude and norms of the society;  life-styles associated with extreme poverty and destitution; hazardous occupation for survival such as scavenging, ship-breaking, medical waste handling;  spatial remoteness; suffering from disease(s) with a social stigma e.g., TB, HIV/AIDS, Leprosy; having physical and/or mental disabilities; differing sexual orientation including sex trading; and  consequences of migration.

Existing policies failed to go more in-depth into the problem and identify the needs and priorities of these populations. The current Social Safety Net programme of the government, consolidating hitherto existing multiple, fragmented, and small-scale safety-net programmes into its social development activities, are not comprehensive and inclusive and fraught with abuse and misuse. The great proportion of the marginalized and socially excluded groups are deprived from the very basic/essential health care services from the formal system, giving rise to large ‘unmet health needs’.  The national databases, as well as some surveillance databases, do not collect and present disaggregated data beyond some common variables, and beyond sub-district. Thus, there is a large gap in data for taking evidence-based decision and policies and programmes to cover these populations, on the journey towards UHC by 2030!

To ensure that the true spirit of ‘inclusion’ underlying the SDGs are translated into effective actions, detailed information on different sections of the population is needed to understand ‘who are left behind’ in the context of a particular country including their needs and priorities for healthcare services. This study aimed to fill-in this knowledge gap in Bangladesh, to inform the relevant stakeholders at the policy and practice levels for designing an evidence-based and inclusive heath system towards UHC by 2030. Due to constraints in time and resources, a Rapid Review (RR) method was adopted ‘to provide actionable and relevant evidence in a timely and cost-effective manner.’

The key findings from this Rapid Review are summarized below, with some recommendations based on the findings.

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• Besides gender-based exclusions which is a cross-cutting issue, there are important categories of populations based on ethnicity and religion, extreme poverty, patron-client relationships, physical and mental disability, sexual orientation, and menial occupation.

• The underlying causes for marginalization and social exclusion include ethnicity, extreme poverty, caste-based social system and associated stigma, migration (e.g., rural to urban migration, landing in pavements or slums), weak and  poorly-resourced and inefficient health systems failing to reach these populations, and lack of understanding and respect for human rights. The most extreme forms of social exclusion occur when unequal power relationship interact with socio-economic, cultural, and political dimensions of the society, operating at the level of individuals, communities, nation states and global regions.

• Like the underlying causes, the process of margnalisation/social exclusion is also varied. These may occur through the process of i) structural barriers to education, employment, and access to land and other resources; ii) patriarchal attitude and norms of the society towards women;  iii) livelihood and life-styles associated with extreme poverty and destitution; iv) hazardous occupation for survival such as sweeping (also involves scavenging and medical waste handling); v) spatial remoteness e.g., living in hard-to-reach areas; suffering from diseases which have a social stigma e.g., TB, HIV/AIDS, Leprosy; having physical and/or mental disabilities; vi) differing sexual orientation and selling sex as a means of living; vii) migration, sudden influx or more subtle on-going phenomenon e.g., rural to urban.

• The existing policies of the government revealed that the various marginalized/excluded groups are touched upon in passing, but failed to go more in-depth into the problem and identify the needs and priorities, for informed design of specific interventions benefitting the marginalized and socially excluded. However women, children, people with disability, and ethnic minority people (tribal people) have specific policies/plans.

• The current Social Safety Net programme of the government, consolidating hitherto existing multiple, fragmented, and small-scale safety-net programmes into its social development activities, are mostly provided by different agencies of the government and mainly target three types of people at risk: i) people who are in food insecurity due to seasonality, disaster or crisis ii) people who are living in structural poverty iii) people with special needs like elderly, widows and disabled. Due to nepotism, social and political pressure from the local elites and lack of integrity of those in charge, well-off people often get included in the program in exchange for under-the-table deals. Also, transfers made under the scheme, whether in cash or kind, is limited to meet the requirement of the beneficiaries under available market realities.

• Whilst there is political commitment from the highest level of the government for achieving UHC by 2030, the great proportion of the above marginalized and socially excluded groups are not accessing the very basic/essential health care services from the formal system for various resons, giving rise to large ‘unmet health needs’.  Though Bangladesh is largely applauded for achieving health related MDGs at aggregate levels, these marginalized and socially excluded groups are miles behind the general population when the outcome are disaggregated with respect to wealth quintiles, gender and other socio-demographic variables.  Shortage or absence or lack of qualified health care professional combined with socio-cultural and financial factors compels the population at the fringes to seek care from traditional, unqualified, and spiritual healers as a last resort.

• The national databases, as well as some surveillance databases, do not collect and present disaggregated data beyond some common variables, and beyond sun-district. Thus, there is a large gap in data for taking evidence-based decision and policies and programmes to cover these populations, on the journey towards UHC by 2030!

Based on the findings above, the following recommendations are made:

·         There is an urgent need for developing a consensus regarding the concept of ‘marginalisation and social exclusion’ at the policy and practice levels (across ministries, sectors and agencies), for bringing relevant stakeholders on board and developing an integrated, comprehensive  and customized intervention for the above population groups.

·         For developing evidence-based and targeted interventions for implementing UHC for these groups, the current data gaps need to be urgently addressed. For example, concerted and concentrated advocacy will be needed to include the information of these groups in the coming rounds of survey of the national databases e.g., BDHS, HIES, FSNSP, BBS SRS, MICS, BD UHS etc. (based on ethnicity, caste, sexual orientation, sex work, spatial location, disability etc. as discussed in the report). Besides, the current surveillance systems in public and non-state sectors also need to be updated along this line.

·         As these populations are sometimes concentrated in specific pockets of the country, these should be included as special statistical entities so that data depths are not lost. We need to go beyond currently used geographical levels of data collection e.g., the PSUs in the BBS surveys.

·         In the short term, a nationwide sample survey on the marginalized and socially-excluded groups, using cluster sampling method, can be done to feed the policy makers and the programme developers. This will help immediate actions to accelerate their journey towards UHC by 2030, along with the mainstream population.

·         These customized and specific interventions should be culture and context sensitive to succeed. Implementation research may be needed to understand their perspectives about illnesses and diseases (Emic and etic perspectives), needs and priorities regarding their health care needs and expectations.

·         A supra ministerial coordination mechanism including the NGO and other non-actor sectors (backed by PM’s office and other centres of power in the current political context) will be needed to see that the policies and programmes are translated into real-life actions, and not drowned under bureaucratic ‘in-action,’ keeping in mind UHC 2030 commitment of the government and ‘leaving no one behind.’

Source: Excerpts from a study “Current scenario of the marginalized population in Bangladesh: identifying data gaps for action towards Universal Health Coverage by 2030”