Sub-theme 1: Vulnerable Populations: Who, Where and Why?
Development must be more equitable if it is to be sustainable. Deepening, divisive and destabilizing inequalities within and among countries are threatening social progress and economic and political stability, affecting all pillars of development including health, human rights, peace and security.
The United Nations Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda called for designing development goals that focus on reaching excluded groups. The vision of “Leave no one behind” focuses on eradicating extreme poverty by 2030 and putting justice and equity at the heart of the new Sustainable Development Goals (SDGs). Learning from the experience of the MDGs, the new 2030 Sustainable Development Agenda is a universal, transformative and people-centered plan of action, strongly grounded in international human rights law and aims to collectively work towards achieving sustainable development through cooperation and integrating social, economic and environmental dimensions of development.
The imperative to promote more equitable development permeates all 17 SDGs of the new Agenda, including through promoting universal, equitable and inclusive access to health, education, food, water, sanitation, justice, opportunities and outcomes across many of the targets. This is further underscored by a cross-cutting commitment to the disaggregation of data, which will help to ensure that no one is being left behind. The new Agenda gives special attention to the poorest, most vulnerable and marginalized, including women and girls, all children, youth, persons with disabilities, people living with HIV/AIDS, older persons, sexual and gender minorities, indigenous peoples, refugees and internally displaced people and migrants.
Vulnerability, broadly defined, can vary significantly within a community and is subject to change over time. Vulnerability is closely associated with poverty, isolation, insecurity or conflict as well as more structural features of society such as gender norms and roles or education and the surrounding legal and policy environment. Factors of vulnerability – sex, age, race, gender, ethnicity, sexual orientation and gender identity (SOGI), displacement, disability, health status - are also, more often than not, intersecting and overlapping, rather than occurring in isolation from each other. Clear correlations can be seen where different factors of vulnerability or characteristics intersect, leading to increased vulnerability and poor health outcomes.
With more than one billion migrants across the globe, in a world that is increasingly interconnected – yet still characterized by profound disparities – the link between migration, human mobility and health is an evolving domain of critical importance, bridging aspects of public health and health security, human rights and equity, and human and societal development.
The conditions in which migrants travel, live and work often carry exceptional risks to their physical and mental well-being, including for those families left-behind. For example, irregular migrants and their families often lack access to health care because of their legal status. In addition, even if migrants have access to health services, they tend to avoid them due to fear of deportation, xenophobic and discriminatory attitudes, and other linguistic, cultural, and economic barriers. From a global health security perspective, the lack of targeted outreach health services and surveillance along mobility pathways undermines the effectiveness of disease control measures. Additionally, more than 50 conflicts around the globe, persisting human right abuses, and environmental changes have produced more than 60 million displaced people world-wide, and this against a general backdrop of mounting xenophobia and anti-migrant sentiments that exacerbate the vulnerability of people seeking protection abroad. This is all the more evident when one considers that lasting conflicts have largely diminished the resilience and the capacity to dispense care of health systems in many parts of the world.
The field of migration and health has also become increasingly important from a sustainable development perspective. Remittances from low-skilled labor migrants from many low-income countries contribute significantly to the economic growth of their country of origin. It is now widely acknowledged that migration carries development potential, owing to migrants’ intellectual, cultural, social and financial capital and their active participation in societies of origin and destination. Nevertheless, discussions of the health and well-being of migrants have not yet gained much momentum in relevant global debates, such as the 2006 and 2013 United Nations High-level Dialogue on International Migration and Development and the Global Forum on Migration and Development. Nor has the concept gained much traction in the discussion and definition of the Sustainable Development Goals.
There are gross inequalities in health between and among countries and vulnerable populations are affected the most. Life expectancy at birth, as an example, ranges from 34 years in Sierra Leone to 81.9 years in Japan. Within countries there are also large inequalities – a 20-year gap in life expectancy between the most and least advantaged populations in the USA. Furthermore, socially-marginalized populations are disproportionately subjected to health vulnerability and inequity. For example, men who have sex with men, female sex workers, and transgender women are 19, 14, and 49 times more likely to contract HIV, respectively, when compared with adults of reproductive age., Persons with disabilities are often excluded from disaster responses and face higher fatality and other health risks in emergencies. Cross-border labor migrants, particularly those under-documented, do not seek healthcare until they reach a critical condition and they often fall outside universal health coverage discussions., Women living with HIV face rights violations in healthcare settings, including treatment refusal, confidentiality breach, and forced sterilization and abortion. People living with neglected tropical diseases are disabled, impoverished, and rendered hopeless with insufficient R&D and policy attention for affordable treatment and care.
While trends from MDG progress reports have shown that some populations are systematically faring worse than others, the purpose of ‘leaving no one behind’ is to recognize that vulnerability occurs in all contexts, and demands that we look beyond the labels to understand what is driving vulnerability, where, and how to mitigate it to promote and protect the right to health.
Though challenges exist and there is much work to be done, there are exciting developments afoot in a variety of disciplines to better monitor social inclusion, exclusion, health inequalities, discrimination and the costs to economies and societies of exclusion, as well as the cost-effectiveness of addressing marginalization and promoting a more universal and equitable agenda. The new SDG Agenda provides a new research imperative to ensure that we have robust information systems that collect and disaggregate data, contain adequate safeguards and draw from multi-disciplinary methods to monitor those being left behind. The nature of those on the margins of development is that they are hard to find in routine monitoring processes. The new SDG paradigm requires that this should no longer be the case.
Sub-theme 2: Interventions to Reach the Vulnerable
Social inclusion is high up in the global policy agenda and is a major focus of the SDGs. Complex demographic, social and economic transitions over the past decades, combined with expansion in education and connectedness, has catapulted the need for social inclusion in developing and developed countries alike. In the realm of health, increased societal expectations, recognition of health as a human right, and the understanding that health matters for social and economic wellbeing have put UHC at the core of policy discussions worldwide.
While there has been significant improvement in global health coverage in recent decades, some groups continue to be systematically left out of quality health services. These groups are often, but not always, the poorest members of their societies. They may have poor access because of their location or social and economic status, but also because of social processes and legal, cultural and political constraints that systematically leave them behind. Social exclusion may be enshrined in law or policy; it can also be practiced by service providers, wittingly or unwittingly, despite being proscribed by law or policy.
Individuals and groups are often excluded or included based on their national and social origin and identities. Quite often, multiple identities overlap to accentuate the impact of exclusion. This can lead to lower social standing, accompanied by lower development outcomes, including poor access to quality healthcare. Examples of socially excluded groups are myriad and include undocumented migrants, guest workers with limited rights, incarcerated populations, the homeless or highly mobile, those diagnosed with mental illness or addictions, those with mental or physical disabilities or living with HIV, those excluded due to gender or gender identity, ethnic, tribal or caste reasons, and those excluded for lifestyle or behavioural reasons, including LGBTI (lesbian, gay, bisexual, transgender and intersex), sex workers, people who use drugs and young or unmarried people seeking sexual and reproductive health care services.
Social inclusion is the process of improving the ability, opportunity, acceptance and dignity of people, disadvantaged on the basis of their identity or origins, to take part in society (World Bank, 2013). Ensuring health coverage to those groups most at risk of being left behind requires that laws and policies promote and protect their right to access health care and address the social determinants of health. Successfully implemented policies such as these can enhances the ability of and opportunities for those most marginalized to fully participate in social and political processes and ensure their right to non-discrimination.
Ability is both innate and acquired; it is acquired ability that policy can strengthen by ensuring, for instance, pre-natal attention to the mother and then on to the individual at every stage of the life cycle. In addition, social inclusion/exclusion is very dependent on social and political ability to engage and share legal and policy decisions that affect their access to services. Ability and opportunity are related, but they are not the same. Access to health care is both a demand side and supply side construct. It may be possible to have perfect supply of opportunity in an ideal world, but some groups may be physically, socially or culturally prevented from accessing them. For instance, women in some communities may need permission to go to the health center, even if they come from well-off families. In other cases, people stigmatized on the basis of their sexual identity may be physically or psychologically prevented from accessing certain services, and women from criminalized populations such as women who use drugs often face even greater stigma than their male counterparts. Finally, the notion of dignity and rights, including the legal right to care, is intrinsic to the design and implementation of policies and programs. Historically excluded groups are also often those that experience stigma and discrimination, humiliation and indignity at the hands of service providers. Thus, they may be unable or unwilling to access to available health care.
It is important to understand the processes of discrimination and exclusion and to guard against them through a range of interventions that target both users and providers. Yet, no single set of policies or programs can be classified as “social inclusion” policy or program. Interventions need to be context specific, depending on the rights that need to be deepened. They must tackle both demand and supply side obstacles, by promoting and protecting the right to health- including but not limited to promoting health-seeking behaviors and facilitating increased access to services as well as ensuring high quality services are delivered without stigma or discrimination and in a safe and secure environment, including legal protections. Understanding the underlying drivers of exclusion is central to developing effective policies to make universal healthcare accessible for all.
The following principles will guide the development of interventions for socially excluded groups:
- Human rights are universal and are applicable for all people without discrimination.
- All people especially those at risk of exclusion must live in a fair and just society where they are respected and protected, so they can achieve their full potential.
- Socially excluded groups are entitled the equitable distribution of health and social resources.
- There can be no UHC without social inclusion. Those who belong to historically excluded groups must be integrated into UHC – as the first mile not the last mile - like all others without discrimination.
- Addressing stigma and discrimination throughout the health, social and community response systems needs to be a priority if we are to achieve UHC.
- The voice of the socially excluded must be reflected in health systems
A taxonomy of interventions to promote social inclusion
The following taxonomy is proposed to identify classes of interventions to promote social inclusion through UHC and underlying interventions.
|Demand side interventions||Supply side interventions|
|Promoting legal literacy, laws, policies and reforms that address the determinants of social inclusion, remove obstacles to social inclusion and promote measures to strengthen social inclusion||Multisectoral interventions, including interventions to address social determinants of health as well as increasing access to justice, to develop UHC and supporting interventions to provide comprehensive, integrated services to the socially excluded|
|Societal and community interventions to reduce stigma and discrimination against socially excluded communities||Expanding physical access to services needed by the socially excluded, including situating services near socially excluded communities and in accessible manner, at times convenient to socially excluded communities. Also recognizing the different needs of excluded women, men, trans people and young people across all categories. Holding health care providers accountable for treating excluded groups with dignity and respect|
|Financial incentives to promote the inclusion of socially excluded groups, including incentives to access UHC services||Conducting regular analyses to understand the needs of the socially excluded|
|The removal of financial obstacles to accessing UHC and associated services, by ensuring the services are free and equitable||Based on an understanding of the needs of socially excluded communities, developing an expanded range of services and instruments. The interventions should explicitly promote rights-based programming and interventions, including programs and approaches to address gender-based barriers to services.|
|Social interventions to increase demand for UHC and related services, by promoting health seeking behaviours and by making the services culturally, socially, legally and psychologically accessible, ensuring the socially excluded do not face stigma and discrimination or experience abuses and violations.||Expanding the provision of socially, culturally and psychologically acceptable service providers and services, which includes recruiting appropriate providers, training providers to be more receptive to the needs and rights of the socially excluded, structuring services appropriately, and sensitivity training and orientation|
|Active promotion of inclusive services through community systems, groups representing socially excluded groups and mass, targeted and social media||Strengthening community delivery systems to provide a vehicle to reach and engage the socially excluded|
|Interventions to strengthen voice, agency and self-empowerment among the socially included and to enable them to participate in the governance of policies and services and monitor how policies are implemented, and services – provided.||Representation of groups who are at risk of being left out, in decision making at the local and through to the national levels.|
To advance understanding and resolve to implement policies and interventions to make UHC inclusive and accessible for excluded populations. This will be achieved through sharing experiences in implementation of policies and programs to enhance inclusion in different settings and groups, including measuring impact of those on better health in excluded populations.
The focus will be on concrete, practical examples of measures to achieve social inclusion – on the how not the what. Wherever possible, real-life experiences and case studies will be used.
Sub-theme 3: Political Economy of Vulnerability and UHC
- To understand and appreciate the human rights and equity principles underpinning universal health coverage and recognise where these rights are not be respected.
- To share lessons on how to extend effective coverage to vulnerable populations, for example people living in fragile states, refugees, internally displaced people, the poor, economic migrants, ethnic minority groups and disadvantaged demographic groups (women, children, LGBT people, disabled people, the chronically sick and the elderly)
- To discuss the political benefits of implementing truly inclusive and equitable UHC reforms that not only “leave no one behind” but also prioritise the needs of vulnerable populations.