BACKGROUND

The Prince Mahidol Award Conference (PMAC) is an annual international conference focusing on policy-related health issues of global significance. The Conference is hosted by the Prince Mahidol Award Foundation, the Thai Ministry of Public Health, Mahidol University and other global partners. It is an international policy forum that Global Health Institutes, both public and private, can co-own and use for advocacy and for seeking international perspectives on important global health issues. The Conference in 2017 was co-hosted by the Prince Mahidol Award Foundation, the World Health Organization, the World Bank, the United Nations Development Programme, the United Nations Population Fund, the Joint United Nations Programme on HIV/AIDS, the International Organization for Migration, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. Agency for International Development, the National Institutes of Health, the Japan International Cooperation Agency, the China Medical Board, the Rockefeller Foundation, the Chatham House, and the Bill & Melinda Gates Foundation with the support from other key related partners. The Conference was held in Bangkok, Thailand, from 29 January - 3 February 2017.

Why Social Inclusion Matters?

The year 2015 marks the endpoint for achievement of the Millennium Development Goals (MDGs). In assessing the MDG response and outlining a plan for the next era of development, 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 development goals. Though the MDGs have made a big progress in solving pressing problems, in some cases they have resulted in a widening of inequalities between groups. National level success achieved from the MDGs did not translate to the same success across different groups of people. Reduction in child mortality in Burkina Faso and Cameroon, for example, are different between the richest and poorest group, whereby the child death rate in the richest 20% reduced much faster than the death rate in the poorest 20%. Moreover, social exclusion has economic consequences in terms of loss of productivities and economic growth, and deprives human capital from the excluded. “Leave no one behind” is, thus, the right direction toward a sustainable development in bringing people left behind to the heart of attention. The SDGs have set an ambitious goal to have a society “that is just, equitable and inclusive, and committed to work together to promote sustained and inclusive economic growth, social development and environmental protection and thereby to benefit all, in particular the children of the world, youth and future generations of the world without distinction of any kind such as age, sex, disability, culture, race, ethnicity, origin, migratory status, religion, economic or other status.” Unlike the MDGs where targets are more relevant to a developing country context, SDGs are relevant to all countries, developed and developing countries alike.

For PMAC 2017, the theme will be in line with the SDGs on social inclusion but will focus on the health of vulnerable populations. Thus, the theme will be “Addressing the Health of Vulnerable Populations for an Inclusive Society”.

How to Measure Social Inclusion?

Converting principle into practice requires a clear understanding of the issues and having measurable targets and indicators. Social exclusion is viewed with different perspectives which will lead to different policy implications. Silver (1994) using solidarity paradigm defined social exclusion as “a disruption of the social ties between society and the individual due to the failure of institutions to integrate individuals into the society.” Amartya Sen (2000) has proposed to consider social exclusion not just related to poverty but to capability deprivation. Sen has distinguished between constitutive relevance of social exclusion and instrumental importance, where the former means that being excluded is the deprivation in itself while the latter refers to relational deprivations that in themselves are not bad but can lead to other deprivations.

The World Bank in their report looked at social inclusion as “The process of improving the terms for individuals and groups to take part in society.” Though different in perspective, there is consensus that social exclusion is multidimensional, dynamic and relational. 

How to measure social inclusion is challenging. There are some efforts to measure social inclusion such as using well-being, better life indicators or Multidimensional Poverty Measure (MPM). A study by Ward et al. in 2013 analyzed four key inter-linking factors of SDH on social cohesion, social inclusion, social empowerment and socio-economic security in order to improve health of the most vulnerable groups of society. They developed a 50-question survey, divided into four categories according to the four factors above. The survey was conducted in 2009-2010 in six research participating countries, namely Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.

Policy and Strategies to Tackle Social Inclusion

To develop an inclusive society needs interventions that are inter-sectoral and contextually relevant. The vulnerable population approach focuses on decreasing health inequalities between socially defined groups may be a better approach compared to population at risk or population approaches. Alleviation of fundamental causes that create vulnerabilities especially in social determinants of health is the key of this vulnerable population approach. The policies and actions included approaches to poverty reduction/eradication, the provision of new services, initiatives to improve access to existing services and/or to improving the co-ordination of policies and new strategies for policies and actions had been mentioned in the final report in 2008 of the Social Exclusion Knowledge Network (SEKN). Improving health equity is at the core of Health 2020 proposed by the EU which emphasized that the strategies for health equity and sustainable development should come together. 

The Territorial Dimension of Poverty and Social Exclusion in Europe (TiPSE) project is the first comprehensive and systematic attempt to map regional patterns of poverty and social exclusion across Europe to inform the decisions of policymakers at EU and national levels. The World Bank proposed to enhance social inclusion by improving ability, opportunity and dignity, while at the same time, paying attention to attitude and perception.

SUB-THEMES 

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.

Guiding Principles

• 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.

Objectives:

• 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

Objectives

• To understand and appreciate the human rights and equity principles underpinning universal health coverage and recognize 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 prioritize the needs of vulnerable populations.