J HEALTH POPUL NUTR 2009 Aug;27(4):426-440 ISSN 1606-0997 | $ 5.00+0.20 ©INTERNATIONAL CENTRE FOR DIARRHOEAL DISEASE RESEARCH, BANGLADESH Relationships of Exclusion and Cohesion with Health: The Case of Bangladesh Heidi Bart Johnston ABSTRACT Public Health Sciences Division, ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh The concept of social exclusion, applied widely in the European Union, has in recent years been gaining use in Bangladesh, mostly by international development agencies. Does this discourse of deprivation, de- veloped in the welfare states of northern Europe, have salience in its application to deprivation in countries like Bangladesh where, for example, 31% of the rural population lives in chronic poverty? The concept of social exclusion has three principal components: a dynamic and relational perspective which requires the identification of who or what causes exclusion; an explicit recognition of multiple dimensions of depriva- tion; and a longitudinal perspective, recognizing that individuals and groups are dynamic intra- and inter- generationally. The Social Exclusion Knowledge Network of the World Health Organization Commission on Social Determinants of Health expanded the concept to include health status as a contributor to and an outcome of exclusion and to show that actors beyond the state or public sector can critically impact exclu- sionary processes. In the Bangladesh application, the relevance of the modified model was explored to find that while there are negative associations between social exclusion and health status, much stronger docu- mentation is needed of the relationship. The modification of including multiple sectors, such as private enterprise and civil society, in addition to the state, as having potential to impact exclusionary processes is fundamental to the application of the social exclusion model in Bangladesh. Key words: Health equity; Social determinants of health; Social exclusion; Bangladesh RELEVANCE OF SOCIAL EXCLUSION THEORY IN BANGLADESH The concept of social exclusion is a relatively new tool for analyzing social disparities in South Asia (1). The concept has its modern origins in France in the 1970s, referring to breakdowns of in- dividuals from society and the state. The concept adapted as it was applied in a more individualistic England and the European Union where a con- cern with fundamental human rights prevails. In these adaptations, the relationships between the individual and the established welfare state remain fundamental (2). In the South Asian context, re- lationships between the individual and the state are far less central. Does the concept of social ex- clusion have sufficient resilience to maintain its value in such contexts? Correspondence and reprint requests should be addressed to: Dr. Heidi Johnston Public Health Sciences Division ICDDR,B GPO Box 128 Dhaka 1000 Bangladesh Email: heidibartjohnston@gmail.com With the question of widespread applicability in mind, the Social Exclusion Knowledge Network of the World Health Organization Commission on Social Determinants of Health reviewed and adapted the social exclusion concept to enhance its applicability and analytical potential. This pa- per applies this modified social exclusion concept in an analysis of different policies and actions im- plemented in Bangladesh that are meant to or do enhance livelihoods. Drawing from these multiple analyses, this paper (a) assesses the applicability of the concept of social exclusion to the Bangladesh context, (b) questions the benefits of introducing a new concept for analyzing policies and actions meant to promote development, and (c) explores the documented relationships between increasing capabilities and resources (i.e. diminishing exclu- sion) and health status. Social exclusion: an evolving concept As applied in this paper, the fundamental char- acteristics of the social exclusion framework are three-fold. First, social exclusion is relational, recog- nizing an interplay between agency and structure (3), acknowledging that social relations are fixed in