SEKN Final Report February 2008 Understanding and Tackling Social Exclusion Final Report to the WHO Commission on Social Determinants of Health From the Social Exclusion Knowledge Network February 2008 Jennie Popay, Sarah Escorel, Mario Hernández, Heidi Johnston, Jane Mathieson, Laetitia Rispel On behalf of the WHO Social Exclusion Knowledge Network Address for correspondence: Professor Jennie Popay Lancaster University; Lancaster LA1 4YT; UK Office +441524 592493; [email protected] 1 SEKN Final Report February 2008 Umuntu ngumuntu ngabantu. (A person is a person because of other people) Exclusion consists of dynamic, multi-dimensional processes driven by unequal power relationships interacting across four main dimensions - economic, political, social and cultural - and at different levels including individual, household, group, community, country and global levels. It results in a continuum of inclusion/exclusion characterised by unequal access to resources, capabilities and rights which leads to health inequalities. 2 SEKN Final Report February 2008 Acknowledgements This report has been written by members of the regional hubs of the Social Exclusion Knowledge Network (SEKN). The SEKN is one of nine global Knowledge Networks established by the WHO (World Health Organisation) Commission on the Social Determinants of Health (CSDH). As with all such reports it has benefited greatly from the input of many people. We are particularly grateful for the collective inputs, contribution and expertise generously offered by other Knowledge Network Members at our meetings and through email exchanges and from authors of the SEKN Background Papers. A full list of these contributors is provided below but we would like to express our particular thanks to Etheline Enoch (UK hub) who made an important contribution to developing the framework for this report, Jackie Cox (UK hub) and Nico Jacobs (South Africa hub) who provided invaluable assistance organising network events. Thanks are also due to Sarah Simpson and Anand Kurup from the World Health Organisation (WHO) Geneva, and Sebastian Taylor from University College London who, as members of the Commission secretariat, have given unstinting support and invaluable guidance. The external referees also deserve a special mention, who despite the challenges of an incomplete draft of the report provided insightful comments and suggestions for improvements for which we are grateful. We regret that we have not been able to respond fully to these due to time constraints. Finally, we wish to thank our institutions, Lancaster University, United Kingdom; Human Sciences Research Council, South Africa; Fiocruz, Brazil; the National University of Colombia and Javeriana University, Colombia, and ICDDR, B, Bangladesh for giving a home to the organisational hubs of the Knowledge Network. Disclaimer This work was made possible through funding provided by the World Health Organisation (WHO). The views presented in this report are those of the authors and do not necessarily represent the decisions, policy or views of WHO or of Commission on Social Determinants of Health (CSDH) Commissioners. 3 SEKN Final Report February 2008 Contributors to the work of the SEKN European Regional Co-ordinating Hub and Central Administrative Hub: Jennie Popay (Hub Co- ordinator and SEKN Chair), Etheline Enoch and Jane Mathieson, Lancaster University, United Kingdom. Southern Africa Regional Co-ordinating Hub and network: Laetitia Rispel (Hub co-ordinator), Sellinah Dumela & Boitumela Molomo, Human Sciences Research Council, South Africa; Cesar Palha de Sousa; Universidade Eduardo Mondlane, Mozambique. South East Asia Regional Co-ordinating Hub and network: Heidi Johnston (Hub co-ordinator) and Abbas Bhuiya; ICDDR,B, Bangladesh; Syed Masud Ahmed and. Sabina Faiz Rashid, BRAC Research and Evaluation Division, Bangladesh; A. Mushtaque Chowdhury, School of Public Health, BRAC University, Bangladesh; Anna Schurmann and Nidhi Khosla, University of North Carolina, Chapel Hill, USA; Wendy Werner, independent consultant; Shimeen Mahmud, Bangladesh Institute of Development Studies. Latin American Joint Co-ordinating Hubs and network: Sarah Escorel (Brazil Hub Co-ordinator) and Ligia Giovanella, National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Brazil; Lenaura de Vasconcelos Costa Lobato and Monica de Castro Maia Senna, Social Service School, Fluminense Federal University and Dario Sousa e Silva, Rio de Janeiro State University, Brazil; Hugo Spinelli, National University of Lanús, Argentina; Research: Patty Fidelis de Almeida, Pedro Herculano G. Ferreira de Souza and Lara Escorel Arouca. Mario Hernández (Colombia Hub Co-ordinator), Manuel Vega and Oscar Rodríguez, National University of Colombia, Bogotá, Colombia; Amparo Hernández and Alejandro Perdomo, Javeriana University, Colombia; Mauricio Torres, Andean Region Coordinator, Asociación Latinoamericana de Medicina Social (ALAMES), Colombia;Arachu Castro, Harvard University, USA; Maria Esperanza Martínez and Sarai Vivas, Central University of Venezuela, Venezuela; Margarita Petrera and Sandra Vallenas, Pontificia Universidad Católica de Perú, Perú. Eastern Mediterranean Region representatives: Aziza Khalidi, Islamic University, Lebanon; Sany Kozman; AIDS Unit Caritas, Egypt. Western Pacific Region & Civil Society representative: Kumanan Rasanathan (previously University of Auckland, New Zealand, now WHO Geneva). Measurement & Evidence Knowledge Network representative: Antony Morgan, National Institute for Health and Clinical Excellence, UK. WHO representatives: Sarah Simpson, Anand Sivasankara Kurup, Sebastian Taylor, Amine Kébé. Other contributors: Nina Larsen, UK (Ghana Case Study); Mwajuma Masaiganah, Civil Society Facilitator, Tanzania; Lareen Newman, Katherine Biedrzycki and Fran Baum, Flinders University, Australia (South Australia case study); Jan Patterson, South Australia Social Inclusion Unit, Australia (South Australia case study); Hani Serag, (Civil Society Facilitator) & Kabir Karim, Association for Health and Environmental Development, Egypt and members of the CSDH Civil Society Reference Group (Civil Society case studies); Almoustapha Alhacen, Aghirin’man, Niger (North Niger case study); Bernice Downey and members of Canadian CRG Aboriginal Sub Committee of the Canadian Reference Group for the WHO CSDH. 4 SEKN Final Report February 2008 CONTENTS EXECUTIVE SUMMARY 7 Part I: INTRODUCTION 23 Chapter 1: The Social Exclusion Knowledge Network and its work 24 Part II: DEFINING AND MEASURING SOCIAL EXCLUSION 32 Chapter 2: The meaning and policy relevance of social exclusion 33 Chapter 3: Assessing the problem and monitoring action 43 Part III: TACKLING EXCLUSIONARY PROCESSES 87 Chapter 4: Contextualising and classifying the policy/action appraisals 88 Chapter 5: State-led policies to address exclusionary processes 93 Chapter 6: Strategic initiatives for policy development and co-ordination 125 Chapter 7: Social movements, community involvement and civil society 140 Chapter 8: The private sector and exclusionary processes 156 Part IV: CONCLUSIONS 166 Chapter 9: Tackling social exclusion – an overview 167 Chapter 10: Recommendations to the WHO CSDH 184 REFERENCES 196 APPENDICES Appendix 1: The policy appraisal analytical framework 201 Appendix 2: List of abbreviations used in the report 205 5 SEKN Final Report February 2008 Tables 1 SEKN Background Papers 2 The EU Laeken Indicators of inclusion/exclusion 3 Pochmann’s Social Exclusion Index – Brazil 4 Examples of Theory-driven Approaches to Measuring Social Exclusion - UK 5 Impact and lessons from Universal Health Care Policies 6 Benefits and Limitations of Conditional Cash Transfer Programmes Figures 1 SEKN Structure and Global Reach 2 Social Exclusion: Discursive Diversity 3 The SEKN Model of Social Exclusion 4 Displacement and Exclusionary Processes in Colombia 5 A Global View of HIV Infection 6 Exclusionary Processes Impacting on Indigenous People in Latin America 7 Map of Human Development Indices 2004 8 A Typology of Actors and Actions to Address Exclusionary Processes 6 SEKN Final Report February 2008 EXECUTIVE SUMMARY: TACKLING SOCIAL EXCLUSION – AN OVERVIEW The Social Exclusion Knowledge Network This is the final report of the Social Exclusion Knowledge Network (SEKN) to the WHO Commission on the Social Determinants of Health. It considers the meanings attached to the term ‘social exclusion’ around the world, presents a conceptual framework for understanding social exclusion in the context of health inequalities and critically reviews knowledge on some existing policies and actions aiming to address social exclusion. Policies and actions included in this report were selected to provide diversity in terms of global reach, the actors involved and the focus of the actions. We have not undertaken a comprehensive review of all potentially relevant policies and action, nor did we not seek to include only policies/actions that could be labelled a priori as good practice: judgement was dependent on the appraisal. The ‘actors’ involved included national and local governments, multi-lateral agencies, community groups and non-governmental organisations and private sector organisations. The policies and actions included approaches to poverty reduction/eradication, the provision of new services, initiatives to improve access to existing services and/or to improving the co-ordination of policies and new strategies for policies and actions to address social exclusion. More details of these appraisals can be