The Needs of the Few: Reflections from PMAC 2017

By Aisha Siddika, Kuhel Islam, and Tasfiyah Jalil


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 well-being 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.

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 from 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 well-being. 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.

This article was originally posted on Dhaka Tribune. The authors are project coordinators at BRAC School of Public Health. 

Why Does Child Marriage Happen?

By Seama Mowri and Saraban Ether

Poster on child marriage seen during a field visit to Bhashantek slum. It reads, “Out of 100 Bangladeshis, 66 young girls are victims of child marriage.”

Although only 16 years old, Ayesha had already been married for nine months when we met her in the Bhashantek slum in Mirpur, Dhaka. While conducting research for the Preventing Early Child Marriage in Urban Slums project, we spoke to Ayesha to get a better understanding of the reasons behind her decision to marry. This is her story.

As an orphan from birth, the responsibility for Ayesha’s care fell on her grandmother. But when her grandmother also died, Ayesha was passed on to the care of one of her paternal aunts. Unfortunately, this arrangement didn’t last either, as Ayesha’s uncle was not keen on having another mouth to feed.

She was then sent to live with another aunt and her cousin who wilfully took her in their care. They loved Ayesha and it seemed that she was finally happy. But when her cousin married a few years later, his new wife disliked Ayesha’s presence and treated her badly. She refused to sit or eat at the same table as Ayesha and blamed her for everything that went wrong in the house. This made life so unbearable for Ayesha that she decided her only option was to get married and move out of the house.

The first suitor her aunt found for Ayesha was interested in the union until his family found out she was an orphan. “His parents were concerned that their son would miss out on jamai-ador (the cultural tradition of pampering the son-in-law with food, accommodation, dowry and all other means of hospitality),” said Ayesha.

The next suitor was Ayesha’s distant cousin. “I heard that he loved me,” she said. “I was so desperate to get married and have a home that I said yes to him. I did not think of anything else.” But after they got married, Ayesha realized the magnitude of responsibilities that came along with being a wife. “I had never seen a wooden stove before getting married,” she said. “But I needed to cook on that stove now. I never cooked or washed clothes before [getting married]; now I have to do all that and more.”

Even though she performs her daily chores, Ayesha’s husband is still displeased and uses any opportunity to beat her. “I cannot sleep on my right side from the beating he gave me last time.”

Now she regrets the decisions she made, which led up to her getting married in such haste. She says that one of the greatest impacts of her marriage is the loss of her independence. “I could go to my cousin’s house whenever I wanted to go. I used to visit Dhanmondi Lake every afternoon with my aunt. But now I don’t have that independence. I want to visit her, but I can’t.”

In addition to Ayesha’s loss of freedom, she now faces pressure to have a baby. “My husband and in-laws want me to have a baby as soon as possible,” she said. “They do not think of my age and that I am only 16.”

Ayesha decided to get married because she felt she had no other way out. She could no longer tolerate the difficulty of living in the same house as her cousin’s new wife. She believed that marriage would give her a better life. But at just 16 years old, she has lost her childhood and opportunities for a brighter future.

Women in Bhashantek with adolescent children participate in a focus group discussion for the Preventing Early Child Marriage project. The majority of these mothers were married as young children themselves.

In a country where 64% of girls are married before the age of 18, it is crucial to examine how to end this all too common practice, and empower girls to overcome the hardships, which lead them to seek early marriage as a means to escape their difficulties.

This particular project on preventing early child marriage is examining the underlying factors that lead girls and their families to make such decisions. While Ayesha’s story is only a snapshot of the research being conducted, the three-year long project will delve deeper into identifying how to delay early marriage and its impact on both girls and boys. Ultimately, the findings from this project aims to help the Government of Bangladesh inform future programme interventions and policies to better serve girls like Ayesha.

Seama Mowri, Project Manager and Saraban Ether, Research Associate work on the Preventing Child Marriage in Urban Slums project under JPGSPH and International Development Research Center (IDRC). Stay tuned for more updates on this project here on the #VitalSigns blog.

New Study: Husbands and Mothers-in-Law Can Help Decrease Adolescent Pregnancy in Bangladesh

Photo credit: Allison Joyce, 2015

Bangladesh has actually done exceptionally well in increasing contraceptive use by more than 50% in the last 40 years. Yet it still has the highest rate of adolescent pregnancy (31%) in all of South Asia. In a society where child marriage remains common practice, tackling adolescent pregnancy can be an uphill battle.

But a recent study conducted about decision-making and contraception use among married girls in Bangladesh has helped shed more light on how to address this issue. Findings revealed that approaching husbands and mothers-in-law through targeted interventions may serve as an effective method to encourage more use of contraception.

The study took place in Rangpur district, which has the country’s highest number of adolescent pregnancies. Conducted by a research team including JPGSPH’s very own Malabika Sarker, the study followed 35 married adolescent girls for a year through interviews about their maternal healthcare-seeking behaviour.

The aim was to understand the girls’ rationales for using or not using contraception. The most common reason they gave for having a child right after marriage was the expectation to bear a child from their husbands and mothers-in-law. They also conveyed a mistrust and fear about the quality and usage of contraception. Further apprehension is caused by misconceptions from other women in the family or neighbourhood, who become the primary sources of information for girls after marriage.

In rural Bangladesh, husbands and mothers-in-law act as the main decision makers in all matters related to childbearing. As the main breadwinners, men ultimately get to make all household decisions regarding health care. But because family planning is still considered a “woman’s issue,” mothers-in-law are also given authority to make decisions.

Thus by creating interventions that target husbands and their mothers and educating them about the benefits of contraception use and the severe detrimental effects associated with adolescent pregnancy, several of the barriers keeping girls from making these decisions can be lifted.

Child marriage cannot be expected to end overnight, but public health practitioners and policymakers need to start considering the matters at hand. Community health workers with the most exposure to these populations must also be trained in order to provide accurate information so that people fully trust and understand why and how to use contraceptives.

However, these findings are not a means to an end; it is now imperative that the wider community and societal actors begin implementing programmes to increase the uptake of contraception to delay pregnancy among adolescent girls. Only then can further policy formulation and implication lead towards decreasing the rate of adolescent pregnancy in Bangladesh.

To find out more about the study, read it here