Spotlight: Reducing stigma and discrimination: Successful
examples from the health care sector in Asia
By HDN Key Correspondent, August 2006
There is no shortage of studies demonstrating that stigma and
discrimination is common in health care settings in Asia. Ask
anyone living with HIV where they experience the most
discrimination based on their serostatus, their occupation as a
sex worker, or their injecting drug use: They will often reply
that health workers are the ones that make them feel the worst.
Stories of segregation in wards, refusal of care, and disclosure
of status are common in the region.
What really works to reduce stigma and discrimination? There is
in fact a very small evidence base for what has been proven to
work. During the session: ‘Stigma and discrimination: The
undoing of universal access’ [at the International AIDS
Conference, Toronto] we heard that there is no longer any reason
for inaction. The tools to measure stigma and discrimination are
available and ready to be adapted to local situations.
One of the most successful illustrations of action has taken
place in India. The capital Delhi is in a relatively low HIV
prevalence area but is in a good position to try out methods
that may be applicable to other parts of the country where there
are more people living with HIV (PLHIV).
The Population Council undertook formative research to measure
the level of stigma and discrimination in three public sector
and one private hospital. They then worked with a local
nongovernmental organisation and PLHIVs to undertake a series of
activities with all levels of health workers to successfully
reduce stigma and the resulting discrimination.
The hospitals developed a set of guidelines that they could
apply as ‘gold standards’ of non-discriminatory care and support
for PLHIV. They created a checklist that could be used to see if
they improved the quality of the care they delivered and they
developed pride as they discovered that they could disseminate
their ‘PLHIV-Friendly Achievement Checklist’ for others to
assess their work.
The methods then used in Delhi were simple. Training was
provided for all health workers in the hospitals, not just the
doctors. Infection control was improved. And voluntary
counselling and testing services were enhanced. Stigma and
discrimination reportedly decreased in all four hospitals. The
only weakness of this approach was that self observation was
used to determine whether anything changed. Patients and PLHIV
were not asked directly whether the behaviour of hospital staff
had changed. But that is no detractor of the success – just a
suggestion to improve it.
The brilliant example of Delhi has not yet been taken up by
other health care institutions in India. But nothing is stopping
UNICEF from promoting the use of these guidelines in the
hospital based prevention-of-mother-to-child-transmission (PMTCT)
programmes they are promoting in India and Myanmar. In addition,
the World Bank, in a new publication released at the conference
– ‘AIDS in South Asia: Understanding and Responding to a
Heterogeneous Epidemic”, has recommended that all countries in
South Asia develop programmes to reduce stigma.
These tools are also being tested in several sites in Vietnam.
With two successful examples in both South Asia and East Asia,
there are no reasons that the activities cannot be replicated to
reach the majority of health care institutions in the most
populous continent. They are inexpensive to implement and it is
simple to set targets for their use. By the end of this year
many Asian countries will have national universal access plans.
How many of them will include achievable targets for reduction
of stigma and discrimination?
HDN Key Correspondent, Thailand
For Population Council PLHIV-Friendly Achievement Checklist:
For new World Bank publication:
(first distributed: August 2006)