Addressing Social Exclusion: Analyses from South Asia and Southern Africa
Johnston, Heidi Bart, Journal of Health Population and Nutrition
In recent years, the health inequities that exist within and between countries have been receiving increasing levels of attention. Socially-determined health disparities, such as the differences in the maternal mortality ratios in Kuwait (4 per 100,000 livebirths), Sri Lanka (58 per 100,000 livebirths), Bangladesh (570 per 100,000 livebirths), and Afghanistan (1,800 per 100,000 livebirths) are increasingly recognized as unfair and avoidable (1). Despite amplified attention on national and global policy agenda, few countries have been able to systematically reduce socially-determined inequities in health (2).
In 2005, the World Health Organization established the Commission on Social Determinants of Health to provide evidence-based advice on how to promote health equity. The Social Exclusion Knowledge Network (SEKN) was established as one of nine knowledge networks supporting this Commission. During a multi-year international assessment, members of the SEKN based in Europe, southern Africa, South America, and South-East Asia surveyed policies and actions that address disadvantage and marginalization. The SEKN found that many policies and actions focus on the groups who are defined as being disadvantaged, marginalized, or excluded from mainstream society but very few policies or actions focus on changing the processes that cause or perpetuate the disadvantage, marginalization, or exclusion.
The SEKN acknowledged and explored relationships among the economic, social, political and cultural processes which exclude access and participation in society and thereby affect health and well-being. The SEKN developed and promoted a framework for policy and programme development and analysis, which focuses on the exclusionary processes that cause problems rather than on particular groups being 'excluded'. This approach directs attention towards the root causes of social exclusion as opposed to a more limited focus on the differential outcomes of certain groups and thus has practical value for policy and programme design and analysis (3).
This special social exclusion issue of the Journal of Health, Population and Nutrition (JHPN) presents original research describing exclusion and its relationships with health and policy analyses that describe policies and actions that were developed or have the potential to address exclusion. Many papers in this issue of the Journal were initially developed as background papers for the South-East Asia hub of the SEKN. The original research articles included in this issue of the Journal make important contributions in the face of the overwhelming need for additional evidence on relationships between social exclusion and health. The collection of papers in its entirety demonstrates the importance of multisectoral approaches to addressing social exclusion: while public-sector commitment is essential, so too is commitment from civil society; non-governmental organizations, and private sectors can also make significant contributions to reducing social exclusion.
In the overview paper titled "Relationships of exclusion and cohesion with health: the case of Bangladesh", I provide background to social exclusion theory and discuss modifications for the application of social exclusion theory to developing-country settings (4). In the paper titled "Living on the extreme margin: social exclusion of the transgender population (hijra) in Bangladesh", Khan et al. present a rich description of social exclusion of the hijra population in Bangladesh, arguing that, before prevention of HIV-transmission interventions can be effective broadly in this population, the underlying factors that drive the hijra to high-risk behaviours must be addressed (5). Koehlmoos et al. quantify the risk factors of the homeless in Dhaka, Bangladesh and identify that, because of their geographical stability, this group can participate in programmes to increase their access to resources of society (6). Modie-Moroka examines relationships among neighbourhood characteristics, social capital, and health outcomes in Francistown, Botswana (7). …