Author: Sean Roberts (Policy and Campaigns Officer, Health Poverty Action)
The commitment to ‘leave no one behind’ is fundamental to global efforts to achieve the Sustainable Development Goals (SDGs). This commitment is especially relevant to Health Poverty Action, because the indigenous and ethnic minority communities that we work with in the Global South are among the most marginalised – and therefore at greatest risk of being left behind.
In the context of maternal health, this marginalisation can be seen in the clear disparities regarding access to services, as well as health outcomes, in women from these communities, in comparison with the wider population. For example, women from the indigenous Mayan population in Belize are approximately twice as likely not to have had any antenatal visits compared to the rest of the population. The disparity in relation to skilled birth attendance in Guyana is even starker: indigenous Amerindian women are approximately five times more likely to have given birth without any skilled attendance than the rest of the population.
These disparities are the result of a combination of factors, including:
Discrimination – Women from marginalised ethnic or cultural groups such as indigenous peoples and pastoralists face multiple layers of discrimination based on being poor, female, and indigenous or from an ethnic or cultural minority.
Cultural barriers – Many indigenous people and those from ethnic minorities do not speak the language spoken by the majority of the population, which means they often do not understand health care workers and have difficulty communicating with them.
Health care may be provided in a setting and in ways that are totally foreign to these women, such as asking them to wear a hospital gown or involving male doctors in delivery.
Access to health care – Indigenous and pastoralist women often lack access to health centres because the centres are based too far away and transport to them is difficult, or because the centres charge fees they cannot afford to pay.
Harmful practices – In some communities, certain practices can cause pregnant women harm or even death. For example, in some parts of Ethiopia, if a woman falls pregnant outside of marriage her abdomen may be heavily massaged to induce an abortion. Coupled with a lack of access to health care, these sorts of practices can result in death or serious injury.
Lack of voice – Indigenous and pastoralist women often lack a voice and this manifests itself in different ways – from being able to make decisions about their own health or about spending money, to having a political voice at the local, regional or national level.
Based on our extensive experience of working with marginalised communities in Africa, South-East Asia, and Central and South America, Health Poverty Action has formulated a set of key principles for addressing these factors through the development of culturally appropriate health systems. In brief, these principles include enabling participation and community feedback, appropriate communication, culturally appropriate services, and forging links between communities and formal services. Detailed discussion of these principles, together with a series of case studies, can be found in our paper ‘Developing culturally appropriate health systems – key principles.’
There is, however, one crucial further barrier to ensuring that the women from these marginalised communities are not left behind in the pursuit of the SDGs: the extreme paucity of the data that is required to monitor their progress. The statistics cited at the begging of this text are taken from the UNICEF-funded Multiple Indicator Cluster Surveys (MICS), which is one of the two main global sources of data on maternal health – the other being the USAID-funded Demographic and Health Surveys (DHS). The problem is that only a small proportion of the MICS survey reports provide data that is disaggregated on the basis of ethnicity.
Of reports covering 74 countries from the most recent two rounds of MICS surveys, only 21 contained disaggregated data on ethnicity – and even among these, the level of disaggregation was often too broad to provide useful data about the experiences of marginalised communities.
The situation regarding the DHS is even worse – none of the reports from the last round of DHS surveys contained data disaggregated by ethnicity.
To have any chance of fulfilling the commitment to leave no one behind, it is essential that steps are taken to address these massive gaps in data. This requires action on a number of fronts:
- National governments must consult marginalised communities about the best ways to collect, analyse and report such data in line with 2030 commitments and train officials to do so. Data must be analysed, published and form the basis for interventions to address disparities.
- International institutions, donors and NGOs must include requirements for ethnically disaggregated data in their own reporting mechanisms as standard.
- Donors to the two leading international health surveys should insist on the inclusion of questions, analysis and publication of all data collected by ethnic categories in all appropriate surveys.
About the author: Sean Roberts is a Policy and Campaigns Officer at Health Poverty Action, which is an NGO that works for a world in which the poorest and most marginalised enjoy their right to health. His previous background includes a range of campaigning roles on human rights, international development, refugee rights, employment rights, and criminal justice.
Together 2030 is a civil society initiative that brings together more than 450 organisations from 89 countries to promote national implementation and track progress of the 2030 Agenda for Sustainable Development.