By Manasee Mishra, IIHMR University, India, and Future Health Systems.
The Promise of Leaving No One Behind
Universal health coverage is aspirational. The commitment to ‘achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ holds within it the potential to lessen the suffering of millions. Health systems that strive to provide care to the most marginalised are inherently ethical and equitable in their approach. However, human beings are not found in silos. Instead, the most marginalised are persons and groups who are at the intersection of multiple social identities - their stories of exclusion and discrimination being due to the compounding effects of such multiple social identities. Recognising and responding to their lived experiences would truly leave no one behind.
Our Intersectional Identities
Our social identities shape our life experiences. Being born into a particular race, for instance, has historically determined the level of education one receives, the kind of work one does, and one’s standard of living. Even day to day experiences of feeling valued or discriminated against are shaped by who we are. Some social identities can be stigmatising and disadvantageous. Some social identities – such as being rich – help in securing privileges in life, be it at the school, workplace or the healthcare facility.
But, human beings do not have a single social identity. Instead, they are at the intersection of multiple social identities such as gender, race, class, disability, age and the like. Together, these social identities shape their experiences including whether they receive healthcare and where they receive such care. The concept of intersectionality has its origins in feminist scholarship of the late 1980s in the USA. Kimberle Crenshaw comments that the ‘single-axis framework’ of treating ‘race and gender as mutually exclusive categories of experience and analysis’ is problematic. With specific reference to the experience of African American women, Crenshaw observes that such a single axis analysis ‘distorts’ their multidimensional experience.
The concept of equity has been useful in looking at individuals and groups which are socio-historically disadvantaged. It has highlighted ‘systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage’. Equity considerations are increasingly guiding actions to consciously address the systematic and avoidable differences that exist between individuals/ social groups. However, the ‘equity lens’ needs to be broadened to capture individuals and groups who are at the intersection of multiple social identities, since our life chances and life experiences are shaped by our intersectional identities.
Towards More Mindful and Responsive Health Systems
Health systems have an ethical imperative of providing care to everybody. Equity is an ethical principle based on distributive justice . Health systems mindful of intersectional social identities would be ethical because of the fairness in the approach. For, intersectionality recognises individuals being members of multiple social identities and the dynamic nature of such membership. It offers a useful conceptual handle to understand people’s experiences with health systems and stories of privilege and discrimination where multiple social identities coalesce to shape such experiences. A recent study illustrates the point. Using intersectional analysis of eye health care seeking among the elderly in India, it shows how gender ‘cross cuts with other social stratifiers, such as age, education, and poverty to determine eye health status’.
Universal health coverage aspires to leave no one behind with the health systems providing care to every individual irrespective of social status and financial security. Using the lens of intersectionality would help health systems to recognise the complex nature of social status. It would make policy makers and practitioners be more mindful of how the underprivileged experience discrimination because of intersectional identities of poverty, gender, disability, race and caste, to name a few. The recognition can lead to health systems being more responsive to those who seek care by understanding the complexity of their lives and mitigating the effects of the compounding social disadvantages they face in receiving care. It would indeed get us closer to universal health coverage.
[This blog references the “Are the Women of Indian Sundarbans Living in Dark: A Gender Analysis of Eye Health Problem” project, which is led by Debjani Barman of IIHMR University and supported by a small grant from RinGs]