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We have entered into the age of sustainable development goals (SDG), and this time is very critical, particularly for our target of making societies inclusive.
The inequalities and financial burdens in health care, which are unfair and unjust, are some of the current concerns of public health professionals. Recognising these ambiguities, more than 900 public health professionals, academics, and representatives from civil society organisations gathered in Bangkok, Thailand to attend the Prince Mahidol Award Conference (PMAC) 2017, a highly prestigious public health experts’ congregation in Asia.
The conference title was “Assessing the health of vulnerable populations for an inclusive society,” which resonates with the third SDG of ensuring healthy lives and promoting wellbeing for all at all ages.
Incidentally, this year’s theme for the World Health Day on April 7 was depression — an overlooked mental health problem globally and an issue that requires more attention in Bangladesh also. Mental health is inseparably connected with people’s physical health, so we cannot ensure physical wellbeing of people by excluding their mental wellbeing.
About 14% of the global disease burden is related to neuropsychiatric disorders — mostly depression. According to the WHO, about 6.4 million people are suffering from depressive disorders in Bangladesh, which is a very big number.
Unfortunately in Bangladesh, due to social stigma and lack of awareness, mental health patients are often advised to visit local healers instead of seeking professional help.
Evidence says depression is often a result of social exclusion and discrimination and can lead to sufferers developing suicidal tendencies. Vulnerable populations are more at risk as they frequently face exclusion and discrimination from mainstream society.
Considering these issues, it is crucial for Bangladesh to make the health of vulnerable populations (both physical and mental) a priority if we want to achieve our target of an inclusive society.
Everyone has a right to receive the highest attainable standard of health care, as stated at the world health assembly in Alma Ata in 1978. For an inclusive society, we need to ensure quality, and respectful and trust-based care for all, particularly those who are vulnerable.
But, whom should we consider as vulnerable? We have to consider people’s vulnerabilities from our own context. In addition to biological vulnerabilities (eg suffering from infectious diseases like tuberculosis, HIV, etc) and economic vulnerabilities (eg living in poverty), we also have to consider relational vulnerabilities (eg social stigma, class system, etc) while addressing the health needs of populations.
Vulnerable populations (eg women, children, and the elderly, particularly from rural, resource-poor settings, and ethnic communities; migrants displaced because of climate and man-made disasters; people with disabilities, diverse gender identities, and orientations) are often neglected entirely by mainstream health service providers.
However, as the PMAC keynote speaker, Nobel Laureate Amartya Sen, said: “Neglecting the health of some is surely a way to perpetuating social injustice.”
One of the practices discussed at the PMAC was people-centred health care, which refers to putting the particular needs of the patient first. Presenters described successful initiatives where service providers came from the same community as the patients so the patients would trust them more.
Presenters also suggested that patients’ agency and transparency in service provision should receive more attention so as to make the system more equitable and people-friendly.
In order to ensure inclusivity, health care providers need to rise above stigma, exclusion, and preconceived notions, and treat communities based on equity and not just equality
Better evidence for better interventions is crucial as emphasised by PMAC attendees. If we do not have accurate data on vulnerable groups, they will remain excluded form receiving services and from policy decisions, allowing discrimination and exclusion to persist.
One of the biggest challenges in implementing evidence-based interventions is that factors such as ethnicity, sexual orientation, disability, etc are not considered during data interpretation, thus pushing the vulnerable further to the fringes.
Health care finance was another focal point at the PMAC, underpinned by an understanding that ill-health breeds poverty. Out of pocket expenditure for health is one of the highest in Bangladesh, which can be a major barrier to all our efforts towards an inclusive and equitable society.
Whether to cover everybody with a modest coverage or provide full coverage to selective vulnerable groups is the question. To balance the two, we can consider different health insurance schemes or health benefit packages for different vulnerable groups depending on the nature of their vulnerabilities.
The PMAC emphasised increasing the number of skilled health care providers, in particular skilled mental health first-aiders who can be non-judgmental and neutral in listening to people’s sufferings and can provide primary instructions (eg follow a “self-help” approach or referrals).
We need to reorient our health workforce to motivate them to work in diverse conditions and situations geared towards a rights-based approach rather than focusing only on physical wellbeing. In order to ensure inclusivity, health care providers need to rise above stigma, exclusion, and preconceived notions, and treat communities based on equity and not just equality.
Addressing the health needs of vulnerable populations and ensuring quality and respectful care for them is also a matter of social justice, as one of the PMAC panelists, Steve Kraus, director of UNAIDS Regional Support Team for Asia and the Pacific, rightly said.
Vulnerable populations are not asking for any additional rights but the same rights that we are all enjoying. To manifest the changes we want, we first require rigorous political scrutiny and attainable commitments.
We must also put forward human rights and social justice agendas and do everything we can to address the inequalities and unmet needs until we have an inclusive health care system in Bangladesh.
Aisha Siddika, Kuhel Islam, and Tasfiyah Jalil are writers working at the James P Grant School of Public Health, BRAC University.