Sabrina Rasheed and Aazia Hossain of iccddr,b write ahead of the session hosted by RinGs – ‘Amplifying marginalized voices: towards meaningful inclusion in social accountability’] – at 11:00 on Friday 12th October at HSR2018 in Liverpool.
Universal Health Coverage (UHC) is a top priority for the Government of Bangladesh. If UHC is achieved, everyone would have access to quality healthcare services without any hardships. However, although Bangladesh has an extensive rural public healthcare infrastructure throughout the country, challenges still persist in the access and use of health services, especially for marginalised groups such as adolescent women and poor working mothers.
The Bangladesh Government has constructed a number of specific policies to try to ensure inclusion of marginalised groups in primary healthcare. For example, Community Support Groups (CSGs) are convened to support frontline Community Clinics (CCs). The CSGs consist of local government leaders, community leaders and members of specific interest groups such as poor people, women and adolescents. Due to the Government’s prioritisation of marginalised groups, representation of poor people, women and adolescents are mandatory in these CSGs.
icddr,b initiated a study in rural Chakaria sub-district of Bangladesh to activate these CSGs to strengthen community participation. Within the study, supported by Future Health Systems and the Research in Gender and Ethics (RinGs) consortium, we used the intersectionality lens to understand the nature of the barriers faced by poor working women and adolescent females in accessing CC services. In addition, we also wanted to understand how the representatives of working women and adolescents in CSGs help to get their voices heard in the delivery of CC services.
We found that the services offered by the CCs in a number of cases did not meet many of the health needs of the adolescents (reproductive health) or working women (acute health problems, and occupational health), although availability of free medication was appreciated. Adolescent mothers lacked awareness of CC services and their access to healthcare was mediated through the household decision makers, making it hard for them to utilise CC services. For working women, the operational hours of the CCs coincided with their work hours and were therefore inconvenient. Women in the rural areas are mostly day laborers. For them, going to the clinic means that they have to miss a day’s work, which prevents them from seeking primary care. When acute health problems occur, mothers did not feel that CCs provided an adequate service.
Neither of these marginalised groups – adolescents and working women – are aware of their representation in the CSGs. In the CSGs group, the members who represent adolescents and women were often chosen quite arbitrarily. They are family members of the political or social leaders. This was an issue for the adolescent members of CSGs group, because they did not feel that they could voice their opinions. The presence of elders in the meeting creates a barrier to adolescents asking questions or expressing opinions. Although we already knew that adolescents and working women lacked access to primary healthcare, the use of an intersectionality lens allowed us to understand the nuances of the marginalisation.
If the voices of the marginalised groups are to be taken into account as mandated in the policy, then the roles and responsibilities of their representatives in the CSGs need to be made real. The adolescent and women members must be supported so that their voices can be brought forward to make primary healthcare more accessible. The use of an intersectionality lens, therefore, has a potential to contribute to the achievement of UHC.