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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

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)