The World We Want, leaving no one behind: did the Go4Health project represent the voices of marginalised communities into the post-2015 global health discourse?

Abstract

The evolution of the Sustainable Development Goals (SDGs) has given rise to a critical post-2015 discourse around what the UN refers to as the World We Want. The unfinished business of the Millennium Development Goals (MDGs) remains conspicuous, with the recognition that inequity has increased, despite its gains. Sustainable development was framed early as a universal agenda, with an imperative to leave no one behind. But how do we hear those who have been left behind? In response, Go4Health, a collaboration between academics and health rights NGOs, was commissioned by the European Union to track the development of the post-2015 goals and specifically to identify the essential health needs of marginalised communities. This thesis is nested within that research, but differentiates itself from it. In a reflexive exploration of how marginalised peoples were heard through the Go4Health project into the post-2015 SDG policy-making discourse, I examine the voices of two marginalised communities in Bangladesh and the Philippines, representing comprehensively what they offered around their lived experience, their understanding of health, their perceived essential needs, and tracking these voices through the Go4Health research output into the global discourse. The objectives of my research are to examine understandings of marginalisation; to explore the experience of marginalised communities with reference to their perceptions of health and health needs; and to review the representation by Go4Health of the voices of the marginalised in the post-2015 discourse. For my primary research, I employed qualitative techniques: focus group discussions with lay community people and key informant interviews with service providers, local leaders, and members of civil society. I further examined whether Go4Health did what it set out to domto hear and represent the voices of the marginalised in the post-2015 discourse, to establish if the left behind are able to be heard. Through a systematic review and thematic analysis of Go4Healthrs publications, I demonstrate that Go4Health did enable the voices of the marginalised to be heard in this global discourse. My engagement and dialogue with communities in the Chittagong Hill Tracts and in the Autonomous Region in Muslim Mindanao exposes the dynamic intersectionality of marginalisation. Lived experiences in their social, environmental and political context bring to light issues around livelihoods, land tenure, and access to basic services, including health care. In the Chittagong Hills, communities described identity and everyday life as shaped by the geography of the region, that also pushes them to the marginsma geography that is remote and difficult, and ljustifiesr the limited state infrastructure provision, the militarised violence, the confiscation of lands resulting in the loss of community livelihoods, but a geography rich in large tracts of forest and arable land, and natural sources of watermsources of sustenance for the communities. In Mindanao, a different scenario, defined by armed violence in a complex interplay of local, regional, and national conflict. Communities live in a typhoon belt, where the only certainty is uncertaintymfood security issues in a region known for agricultural production and export, housing that is frequently destroyed or abandoned, and peace that is elusivemwhere change is only possible through informal connections with the local elite. The concerns of these communities, and of those in 7 other countries, are all synthesised in Go4Healthrs reports and publications targeted to the post-2015 SDG discourse. Sometimes homogenised and filtered, their voices are heard, represented in global health discourse, and even acknowledged by the UN. Yet the marginalised continue to be marginalised: politically pushed aside with promises of change with little or no follow through from state governments, their capabilities for exercising freedom of agency and well-being in contexts of structural violence are severely constrained. I conclude that representing the voices of the marginalised in wider discourse is possible. But they also need resources for critical health literacy and capability enhancement, which requires substantial change in social, political, and economic structures. Enabling the marginalised to truly speak, to have agency in their own communities and states, requires the kind of global change that the rhetoric of the SDGs speaks to: end poverty in all its forms; achieve food security and improved nutrition; achieve gender equality; ensure healthy lives; ensure water and sanitation; ensure access to energy; inclusive economic growth that entails full and productive employment; build resilient infrastructure; reduce inequality within and among countries; make human settlements inclusive, safe, and resilient; ensure sustainable production and consumption; combat climate change; protect and restore terrestrial and marine resources and ecosystems; promote peaceful and inclusive societies; and strengthen the means of implementation for a global partnership for sustainable development. Overarching all of this is the precondition of globalmand national and localmpolitical will and good governance. Only then can meaningful engagement and participation occur for realizing the World We Want.