Partnership to ensure the sustainability of a public health palliative care project in Bangladesh through community theatre

姑息治疗本质上是对临终病人的护理。虽然最近人们承认获得姑息治疗是一项人权，但提供姑息治疗也被认为是一项全球健康挑战。几乎80%可以受益于临终关怀的成年人目前生活在低收入和中等收入国家，无法获得大多数发达国家预期的临终关怀服务水平。在全球在姑息治疗的框架和实践方面存在差异的背景下，作者认为，寻求一个提供全民健康覆盖的全球卫生系统应该将姑息治疗作为基本目标。公共卫生姑息治疗--对绝症患者的护理应该回归社区的想法--已经获得了全球的关注。我们打算发起的社区发展模式是以社区剧院的传统和做法为基础的。目前的世界姑息治疗发展地图显示，孟加拉国属于3a类，这意味着存在孤立的姑息治疗服务和培训提供。最近的一项情况分析显示，尽管孟加拉国在任何时候都有大约60万名无法治愈的患者，但该国只有全面的姑息治疗计划，所有这些计划都设在首都达卡。2013年，这些方案为不到1500名患者提供了服务。在孟加拉国的城市贫民窟，贫困使限制生活条件的影响对家庭和社区成员造成毁灭性的影响。受其他社区驱动的公共卫生姑息治疗方法的启发，BSM医科大学(BSMMU)姑息治疗中心于2015年启动了一个试点项目，在达卡的城市贫民窟提供姑息治疗。最近对以贫民窟为基础的社区姑息治疗项目的评估发现，尽管接受姑息治疗的患者对项目活动感到满意，但更广泛的贫民窟社区对该项目的参与非常有限。这被认为是对贫民窟项目可持续性的重大威胁。社区对公共卫生的参与至关重要，以确保调动更多的资源，增强社区的能力。我们的目标是发展一种创新的跨学科跨学科合作伙伴关系，以支持孟加拉国城市贫民窟姑息关怀项目的可持续性，通过开发一种文化上合适和科学上合理的战略，通过“社区剧院”加强公众参与。社区剧院被公认为是一种有效的方式，可以让社区成员参与持续的反思活动和审美实践，以帮助解决和反思社区关注的问题。将根据当地对死亡、临终关怀和临终关怀做法的社会和文化理解的民族志探索，为社区剧院编写剧本。剧本将由贫民窟社区的成员表演，由孟加拉国最大的非政府发展组织BRAC的社区剧院股提供协助。然后我们将对演出进行评估。这项试点活动中涉及的过程将被记录和拍摄，这些记录稍后将用于评估学习结果，以及通过ART制定公共卫生姑息治疗的社区参与战略。建立这一伙伴关系将为医学、人文、艺术和发展领域的研究人员和从业者提供一个独特的机会，使他们能够相互交流，对公共卫生姑息治疗产生新的见解，并发展跨学科的研究能力。这种伙伴关系的经验将成为后续资金申请的基础，以便为孟加拉国及其他地区资源匮乏的环境提供强有力的、对文化敏感的公共卫生姑息治疗的证据。

Palliative care is essentially care for the dying. While access to palliative care has recently been acknowledged as a human right, providing palliative care has also been recognized as a global health challenge. Almost eighty per cent of adults who could benefit from palliative care are currently living in low and middle-income countries and do not have access to the levels of palliative care provision expected in most developed countries. In this context of global disparity in the framing and practice of palliative care, the authors argue that the quest for a global health system offering universal health coverage should include palliative care as a fundamental goal. Public health palliative care - the idea that care for terminally ill people should be returned to communities - has gained global interest. The community development model which we intend to initiate is based on the traditions and practice of community-based theatre. The current map of world palliative care development shows Bangladesh as being in category 3a, which means that isolated palliative care services and training provision exist. A recent situation analysis revealed that although Bangladesh has approximately 600,000 incurable patients at any point in time, the country only has comprehensive palliative care programs, all of which are based in the capital city of Dhaka. These programmes served less than 1500 patients in 2013. In the urban slums of Bangladesh, poverty makes the impact of life-limiting conditions devastating to family and community members. Inspired by other community-driven, public health approaches to palliative care, the Centre for Palliative Care (CPC) of the BSM Medical University (BSMMU) initiated a pilot project in 2015 to provide palliative care in urban slums in Dhaka. A recent evaluation of the slum based community palliative care project found that although the patients receiving palliative care are satisfied with the project activities, the involvement of the broader slum community with the project is very limited. This was identified as a major threat to the sustainability of the slum project. Community participation in public health is crucial in order to ensure mobilization of greater resources, and greater empowerment of the community. We aim to develop an innovative boundary-crossing interdisciplinary partnership to provide support to the sustainability of the urban slum palliative care project in Bangladesh, by developing a culturally appropriate and scientifically sound strategy for enhancing public engagement through 'Community theatre'. Community theatre is recognised as an effective way of engaging community members in continuous reflective activities and aesthetic practices to help address and reflect upon community concerns. A script will be developed for a community theatre, based on an ethnographic exploration of local social and cultural understandings of death, dying and end of life care practices. The script will be performed by members of the slum community, facilitated by the Community Theatre Unit of BRAC, the largest Non-Government Development Organization in Bangladesh. We will then appraise the performances. The processes involved in this pilot activity will be documented and filmed, and these recordings will later be used to assess the learning outcomes as well as to develop a community engagement strategy in public health palliative care through art. Establishing this partnership will provide a unique opportunity to researchers and practitioners of medicine, humanities, art and development, who otherwise do not work together in Bangladesh, to interact and generate new insight on public health palliative care as well as develop interdisciplinary research capacity. This experience of partnership will form the basis for subsequent funding applications to generate evidence on robust and culturally-sensitive public health palliative care for resource-poor settings in Bangladesh and beyond.