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. 

Let’s Talk About Universal Health Coverage

By Dr. Nahitun Naher


Put very simply, universal health coverage (UHC) means “every person, everywhere, has access to quality healthcare without suffering financial hardship.” This goal is rooted in the concept of human rights to health, which also makes sense economically. However health system gaps remain a barrier, jeopardising the lives and financial wellbeing of millions of people globally. There are still too many countries that have failed to invest enough in health.

The journey towards achieving UHC actually began in 1978 through the Alma Ata Declaration of “Health for All”. But almost three decades later, the WHO Health Systems Financing Report in 2010 finally emphasised for the first time that it is possible for every country to mobilise necessary funds towards achieving UHC. Following that, in a historic resolution in 2012, the United Nations unanimously endorsed UHC as a priority for every country.

The momentum towards UHC turned into a commitment when more than 500 organisations across the health and development sector joined the Rockefeller Foundation in launching the first-ever UHC Day with the slogan ‘Health for All, Everywhere’ on December 12, 2014. Ever since, the global consensus that UHC is a smart investment and an achievable goal has grown.

The striking fact that 400 million people around the world lack basic healthcare services while 17 per cent are impoverished by health costs came out in the first UHC Global Monitoring Report in 2015. This triggered the drive towards UHC and was endorsed by 267 economists who declared UHC a smarter investment.

The year 2016 started with high hopes for UHC as world leaders including the G7 and African heads of state launched UHC campaigns in their countries. This affirmed that health is a human right and no one should go bankrupt when they get sick. Finally, in September 2016, WHO Director General Margaret Chan announced the International Health Partnership for accelerating progress toward UHC by 2030.

Throughout this journey, an international coalition for UHC has emerged involving 739 organisations in 117 countries, which celebrates Universal Health Coverage Day on December 12. This has become the annual rallying point for the growing movement towards health for all.

In Bangladesh, high out-of-pocket expenditure for health is driving people into poverty. Inadequate healthcare financing, inequity in health financing and utilisation, inefficient use of existing resource, inadequate health workforce and their skill-mix imbalance, and the rapid rise of non-communicable diseases are placing more barriers in our paths towards achieving UHC.

However it is promising to see that the Government of Bangladesh has expressed a strong commitment towards achieving UHC. This is reflected in the Government’s seventh Five-Year Plan where UHC has been prioritised. The Health Care Financing Strategy 2012-2032, and National Social Security Strategy 2015 have incorporated UHC by focusing on strengthening financial risk protection and extending health services and population coverage especially to poor and vulnerable populations.uhc-day-badge

This UHC Day, you too can “Act with Ambition” to express solidarity towards achieving UHC. If you are in Dhaka, Bangladesh, please do join our UHC Day Rally on December 12. For more information, please check the Facebook Event page here.

Dr. Nahitun Naher is a senior research associate at the Centre of Excellence for Universal Health Coverage at James P Grant School of Public Health, BRAC University.