“Am I audible? Am I visible?” Abheena Aher (National Programme Manager, Global Action for Trans Equality, India) asked the audience at the recent Prince Mahidol Award Conference in Bangkok, equating the invisibility of those excluded from society to transparent glasses through which people see without acknowledging the individual or human being.
From a personal perspective, this statement and indeed the whole conference were a real eye opener. Having never before felt ‘excluded’ in society, the event provided me with the opportunity to hear about the harsh realities of social exclusion from the marginalized individuals who find themselves invisible to the rest of society.
The event brought together 888 participants from 72 countries, from members of minority groups to politicians to researchers, academics and activists, to deliberate on ‘addressing the health of vulnerable populations for an inclusive society’. The most compelling presence was that of the 44 civil society and NGO representatives on stage. This is an important and timely topic when increasingly nationalist policies seem to threaten the existence of diverse and cohesive societies. It is also an opportune time to address the health of vulnerable populations in the context of the SDGs which focus on leaving no one behind.
Existing and emerging causes of vulnerability
In his keynote speech, Amartya Sen classified some causes of vulnerability as biological, economic, structural, knowledge related and relational. Biological vulnerability refers to having diseases with unknown or imperfect or very expensive cures (here, the resistance to antibiotics was cited as a new vulnerability). Economic vulnerability arises from living in poverty making people more susceptible to illness. Structural vulnerability arises from deficiencies in sanitary and other facilities which can have disastrous effects on health. The inability to make use of existing knowledge also makes people vulnerable, such as adopting behaviors like smoking, regardless of the evidence available showing its detrimental effects on health. Finally, relational vulnerability stems from stratifications in society relating to social barriers such as historically established caste systems in India or more modern divisions related to class and occupational disadvantage. All these barriers cause social inequity. Therefore, the problem of inequality has to be seen as a pervasive challenge that demands a much broader change well beyond the medical realm.
It is also not only about being a member of just one disadvantaged group; intersectionality often predisposes individuals to extreme vulnerability. The dimensions that drive vulnerability (gender, religion, sexual orientation, disability status, ethnicity, employment status and location) can co-exist, more often than not, and create adverse outcomes for such individuals. Therefore, tackling issues of one disadvantaged group may not be adequate to holistically address the underlying causes of social exclusion.
Achieving Universal Health Coverage (UHC)
“No one should say that UHC is unaffordable or they don’t know how to do it.”
Gro Harlem Brundtland, PMAC 2017
Dr Brundtland highlighted the experiences of Thailand, Sri Lanka, Delhi-India, Ethiopia and Rwanda to substantiate how countries at all income levels can move towards UHC. She espoused progressive universalism as the path to make progress towards UHC, in which everyone receives a package of primary healthcare services free at the point of delivery. However this would require a redistribution of resources to cater to the needs of vulnerable and excluded groups as generally their health needs are greater.
Meeting the needs of vulnerable communities is integral in realizing the goal of UHC through adopting a people-centred and human rights-based approach. Communities must be empowered to be at the center of the solution rather than be passive recipients of interventions that are not resonant with their needs. They should be properly informed of their rights: right to health, right to education, right to equal opportunities, right to organize themselves and right to voice their opinions.
Making vulnerable populations more visible
One of the major barriers to addressing the needs of vulnerable groups is scarcity of data. These groups will remain invisible as long as we do not capture them in information systems. By counting we give them, they are given an identity that they have been denied.
As summed up by one of the panelists, common across all socially excluded and vulnerable groups regardless of the country they come from are the need for visibility and the opportunity to participate in decision making that affects their life. It’s not only about creating people centered care through effective laws and policies but also addressing attitudes that determine actions towards these marginalized populations. What is needed to address vulnerability and social exclusion is a combination of top down approaches from responsive and accountable governments and bottom up approaches through community engagement and active citizenship.
‘Social inclusion is often not about doing more, it is about doing things differently’- Mr. Monthian Buntun, Conference synthesis
The Conference proposed several actions in support of social inclusion. First and foremost is the role of the State to devise mechanisms across sectors to tackle social inclusion and monitor progress and ensure equal opportunities in markets, services and spaces for all.
The health sector can bring about change in transforming education to create a more socially accountable health workforce. Inclusion of students from socially excluded groups in the health workforce can ensure more dignified and respectful services to respective populations. We need to support collaborative governance for health to create effective dialogue between the community and the healthcare providers.
We must start by putting vulnerable communities at the centre of the solution to drive change that will ultimately realize a transformation in addressing the health needs of vulnerable people.