Exclusionary processes create inequitable distribution of resources and unequal access to capabilities and rights necessary for human development (Popay et al., 2008). Social exclusion mediates access to services, which has a strong impact on human development outcomes. Sometimes marginalised groups are directly discriminated against and stigmatised, but they are also structurally excluded by factors including geographical distance from services, language barriers, physical difficulties, or unsupportive laws and policies. Human rights-based approaches are particularly important for tackling social exclusion.
Lack of clarity on what ‘social exclusion’ means makes measuring its relationship with human development difficult (Popay et al., 2008). There is no agreement on social exclusion as a broad concept rather than a state affecting certain groups, and it is not clear whether exclusion is a risk factor or an outcome or both for human development processes (Popay et al., 2008). Most studies focus on a single dimension of exclusion, so there is a large body of evidence on those specific dimensions.
There is most evidence on discrimination and exclusion in the health and WASH sectors. There is a strong focus on people living with disabilities, although still insufficient evidence on this group. There is almost no information on social exclusion and sexual and reproductive health except for PWD, so in this chapter the SRH and health sections have been merged. Children with differing and increased learning requirements still face inequalities in education. Most focus is on girls, and children living with disabilities. The literature on WASH and social exclusion mainly focuses on access to water and accountable water services, and there is a growing literature on slum dwellers. Ethnic minorities, indigenous peoples and low-caste people remain less visible in these sectors. Women and girls are more excluded than men and boys.
The disability literature highlights an important lesson for social exclusion: access to the necessary information and services are mediated by attitudes and ignorance about disability issues, rather than by the disability itself (Groce, et al., 2009).
Popay, J., Escorel, S., Hernández, M., Johnston, H., Mathieson, J., & Rispel, L. (2008). Understanding and Tackling Social Exclusion. Final Report of the Social Exclusion Knowledge Network of the Commission on Social Determinants of Health. Geneva: WHO.
In the SEKN conceptual model exclusion is viewed as a dynamic, multi-dimensional process driven by unequal power relationships. It has four main dimensions – economic, political, social and cultural – and operates at different levels, including individual, household, group, community, country, regional and global. The report provides case studies on social exclusion, an overview of its meaning and measurement, and a review of policies and actions undertaken by states, civil society and the private sector.
See full text
Health and Sexual and Reproductive Health
Exclusionary processes restrict social, cultural, economic and political participation, which has negative impacts on health and wellbeing (Popay et al., 2008). The poorest and most marginalised people are usually the least able to claim their health rights (Lang et al., 2013). Marginalised groups often experience discrimination at the point of service (Govender & Penn-Kekana, 2008; Berlan & Shiffman, 2012). This is often shaped by the gap between patient and provider in gender, class, caste, or ethnicity (Govender & Penn-Kekana, 2008). Minority ethnic or marginalised groups are less likely to seek health treatment (Thornicroft, 2008), as are urban slum-dwellers (de Snyder et al., 2011).
People living with disabilities are more likely to seek healthcare, but are less likely to receive adequate care (Lang et al., 2013). They are less likely to have regular employment, and are therefore less able to pay for healthcare (Lang et al., 2013). PWD are more likely to experience physical, emotional, and sexual abuse and other forms of gender-based violence, more likely to become infected with HIV and other STIs, and sometimes experience forced decisions about their SRH (Groce et al., 2009). WHO recommends that SRHR programmes and activism include disability needs, rather than creating separate programmes (Groce et al., 2009). People living with disabilities have historically experienced medical professionals exerting undue influence on their decision-making, such as their choice to attend school, and right to marry (Lang et al., 2013).
The type of health issue may itself cause worse human development outcomes. Mental health disorders carry a greater degree of stigma and discrimination than physical health conditions, and people with mental health conditions are very likely to be socially excluded (Thornicroft, 2008). Aside from financial barriers and lack of knowledge, the social factors creating this situation are: 1) reluctance to seek help because of the anticipation of stigma; and 2) reluctance of diagnosed people to advocate for better mental health care for fear of shame and rejection on disclosure (Thornicroft, 2008). HIV is highly stigmatised and isolating (Popay et al., 2008). Populations at high-risk of HIV, such as people who inject drugs, men who have sex with men, and sex workers, are often highly stigmatised and experience structural barriers to accessing care and prevention services (Gruskin et al., 2013). Harmful laws and policies create barriers that inhibit an effective HIV response, which is especially damaging for populations already marginalised (Gruskin et al., 2013).
Lang, R., Groce, N., Cole, E. (2013). Conceptualising the linkages between the social determinants of health and disability (Leonard Cheshire Disability and Inclusive Development Centre, Working Paper Series, no. 19). London: LCDIDC.
This paper outlines the linkages between two policy directives: the Social Determinants of Health framework and disability issues. The analysis highlights strong similarities and synergies, particularly in promoting a human rights agenda and addressing the inequalities and inequities in access to healthcare and rehabilitation services. Such inequalities must be placed in the context of much broader social, political and economic contexts within and between countries.
See full text
Thornicroft, G. (2008). Stigma and discrimination limit access to mental health care. Epidemiologia e Psichiatria Sociale, 17(01),14-19.
Why do people avoid seeking care for mental health disorders? Evidence from descriptive studies and epidemiological surveys suggest that factors increasing the likelihood of treatment avoidance, or long delays include: 1) lack of knowledge about the features and treatability of mental illnesses; 2) ignorance about how to access assessment and treatment; 3) prejudice against people who have mental illness; and 4) expectations of discrimination. These results appear to be consistent across a wide range of settings and conditions.
See full text
de Snyder, V. N. S., Friel, S., Fotso, J. C., Khadr, Z., Meresman, S., Monge, P., & Patil-Deshmukh, A. (2011). Social conditions and urban health inequities: realities, challenges and opportunities to transform the urban landscape through research and action. Journal of Urban Health, 88(6), 1183-1193.
This secondary review of literature describes how social exclusion contributes to urban health inequities. Poorer health outcomes are widely observed among socially excluded urban residents, particularly slum-dwellers. Factors influencing health outcomes include: education, employment, health care services, social capital and social networks. Lower levels of any of these factors affect health outcomes, and socially excluded groups are much more likely to have lower levels.
See full text
Groce, N.E., Izutsu, T., Reier, S., Rinehart, W., & Temple, B. (2009). Promoting sexual and reproductive health for persons with disabilities: WHO/UNFPA guidance note. WHO: Geneva.
SRH for people living with disabilities deserves attention because these needs have been widely and deeply neglected. PWD have equal rights to be sexually active as those without disabilities, but often do not receive general or specific information and support about their SRHR. This guidance note lays out a five point framework for inclusion: 1) establish partnerships with organisations of PWD; 2) raise awareness and increase accessibility within own organisations; 3) ensure that all sexual and reproductive health programmes reach and serve PWD; 4) address disability in national SRHR policy, laws, and budgets; and 5) promote research on SRHR of PWD at local, national, and international levels.
See full text
Gruskin, S., Ferguson, L., Alfven, T., Rugg, D., & Peersman, G. (2013). Identifying structural barriers to an effective HIV response: using the National Composite Policy Index data to evaluate the human rights, legal and policy environment. Journal of the International AIDS Society, 16(1).
This paper examines law and policy data from 171 countries to assess attention to human rights in national legal and policy environments. It looks specifically at the health and rights of key HIV populations such as people who inject drugs, men who have sex with men and sex workers. Most countries (78 out of 106) report the existence of laws and policies that make it harder for key populations to access HIV services. Yet there are also laws and policies that positively affect access to HIV-related services. A supportive legal environment can play a strong role in building a responsive framework for HIV services.
See full text
Social factors shape access to school, and broadening access to education means targeting specific groups of children who are excluded. Intersecting inequalities mean that age, gender, location, class, ethnicity and income all affect how well children are able to learn (Save the Children International, 2013). Inequalities still persist in access to schooling; although many more girls are now in school, children living with disabilities, children from ethnic or religious minorities or those in remote locations, still do not have sufficient access to school (Hossain, 2010). Only 10 per cent of children living with disabilities are in school (Miles & Singal, 2010). Exclusion from school has multiple impacts on perpetuating poverty (Hossain, 2010).
Children who are in school face problems of inequitable quality of learning when schools do not meet children’s differing and specific needs (Save the Children International, 2013). The already disadvantaged groups suffer most from inadequate teaching, facilities and materials (Save the Children International, 2013).
There is a debate in policy between the Education for All (EFA) and the inclusive education agendas (Miles & Singal, 2010). EFA is a rights-based commitment to ensure every child and adult receives basic education of good quality. It aims to be an inclusive agenda that reaches all learners, but has historically overlooked disability. There is a growing agreement among international agencies that children living with disabilities should be integrated into mainstream programmes and schools. The inclusive education agenda presses for developing inclusive schools that respond to the needs of all learners, no matter their ability level. Inclusivity has no consensus in the literature, and does not provide conceptual clarity, but inclusive education is commonly understood as being mainly about children living with disabilities. In practice, this often means separate special schools.
Save the Children International. (2013). Ending the hidden exclusion: Learning and equity in education post-2015. Save the Children International.
This paper discusses the ‘learning crisis’ for in-school children. Although many more children are now attending school, a large number of them are not learning the basics and are struggling to achieve learning goals. Children with pre-existing disadvantages suffer most. This paper puts forward a framework for the post-2015 goals which focuses on inequity and quality in schools.
See full text
Hossain, N. (2010). School exclusion as social exclusion: the practices and effects of a conditional cash transfer programme for the poor in Bangladesh. The Journal of Development Studies, 46(7), 1264-1282.
This article argues that being excluded from school leads to further social exclusion. Exclusion from education increasingly entails exclusion from economic opportunities, and from knowledge of the tools, language and actions required for citizen engagement with the state. The case study of a cash transfer programme in Bangladesh shows that this programme tends to reinforce social inequalities by failing to target the ultra-poor.
See full text
Miles, S., & Singal, N. (2010). The Education for All and inclusive education debate: conflict, contradiction or opportunity? International Journal of Inclusive Education, 14(1), 1-15.
This paper explores the history of the international Education for All (EFA) programme and its tendency to overlook some marginalised groups of children, in particular those seen as having ‘special educational needs’ or impairments and disabilities. Inclusive education is in part a response to this agenda, and is seen as focusing mainly on children living with disabilities, which fills the gap left by EFA. The paper argues for greater collaboration and synergy between these initiatives, and suggests ways in which practitioners and policy makers can develop more sustainable, and context‐appropriate, policies and practices.
See full text
The most commonly noted inequalities in the WASH sector are between rural and urban populations, and particular socio-economic groups (Pullan et al., 2014). Narayan et al. (2011) note that WASH services often do not reach those most in need and highlight three barriers to social inclusion in WASH: institutional, environmental and attitudinal. Programmes in South Asia which have tackled all three barriers together have been shown to be successful.
Community-Led Total Sanitation (CLTS) aims to facilitate improved sanitation through community awareness-raising and ownership. Although it aims at inclusion, PWD and other socially excluded people tend to have their needs overlooked, or to be represented by others at community meetings (Wilbur & Jones, 2014).
The design of facilities is crucial to make them accessible to PWD. Technical barriers include steps, height, and distance of facilities, lack of transportation, and unsuitable equipment; while social barriers include stigma, low self-esteem if requiring help to use facilities, lack of understanding from service providers, and lack of knowledge about where to access services (Groce et al., 2011; Lang et al., 2013). Despite these known challenges, there is no body of knowledge on the WASH or health needs of people living with disabilities (Groce et al., 2011). The CLTS programme provides some concrete recommendations for improving inclusion (Wilbur & Jones, 2014).
Groce, N., Bailey, N., Lang, R., Trani, J. F., & Kett, M. (2011). Water and sanitation issues for persons with disabilities in low-and middle-income countries: a literature review and discussion of implications for global health and international development. Journal of Water and Health, 9(4), 617-627.
How do people living with disabilities access WASH? This comprehensive literature review presents what is currently known about access to water and sanitation for PWD in low- and middle-income countries from the perspective of both international development and global health. It identifies gaps in research, practice and policy that are of pressing concern if the water and sanitation needs of this large population are to be addressed. It emphasises that there are low-cost, low-tech interventions that work, such as universal design, but that there are few documented examples of good practice, and most are small-scale.
See full text
Wilbur, J. & Jones, H. (2014). Disability: Making CLTS fully inclusive (Frontiers of CLTS: Innovations and Insights Issue 3). Brighton: IDS.
This paper focuses on people living with disabilities and their particular needs for access to WASH. The paper acknowledges the many forms of disability. PWD tend not to be present at CLTS community triggering events. They often lack voice in the community, have their needs overlooked, and may even be hidden by their families. They face physical, organisational and institutional barriers. The paper outlines how CLTS facilitators can include PWD. It highlights that many of the lessons from PWD can be applied to other excluded groups.
See full text
- HEART. (2011). Language of instruction (HEART Helpdesk report).
- HEART. (2013). Inclusive and effective schools (HEART Helpdesk report).
- HEART. (2013). Mother tongue education – Girls and poor/vulnerable children (HEART Helpdesk report).
- HEART. (2013). Universal design of schools and classrooms( HEART Helpdesk report).
- Heise, L. (2013). STRIVE and the drivers of HIV (HEART multimedia resources).
- Paxton, W., (2013). Will Paxton on opportunities to address inequality in education (HEART multimedia resources).
- UNICEF. (2013). State of the world’s children 2013: Children with disabilities. United Nations Children’s Fund.
- Walton, O. (2011). Self-esteem, shame and poverty (GSDRC Helpdesk report).
- Walton, O. (2012). Economic benefits of disability-inclusive development (GSDRC Helpdesk report).
- WHO & World Bank (2011). World report on disability. World Health Organization.