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垂死者的护理。虽然获得姑息治疗最近被承认为一项人权，但提供姑息治疗也被认为是一项全球健康挑战。近80%的可受益于姑息治疗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所期望的姑息治疗服务水平。在姑息治疗的制定和实践存在全球差异的背景下，作者认为，寻求提供全民健康覆盖的全球卫生系统应将姑息治疗作为一个基本目标。公共卫生姑息治疗--即对绝症患者的护理应该返回社区的想法--已经引起了全球的兴趣。我们打算推行的社区发展模式，是建基于以社区为本的戏剧传统和做法。目前的世界姑息治疗发展地图显示，孟加拉国属于第3a类，这意味着存在孤立的姑息治疗服务和培训。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60万无法治愈的病人，但该国只有全面的姑息治疗方案，所有这些方案都设在首都达卡。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，贫穷使限制生活的条件对家庭和社区成员造成毁灭性的影响。受其他社区驱动的姑息治疗公共卫生方法的启发，BSM医科大学（BSMMU）姑息治疗中心（CPC）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。最近对贫民窟社区姑息治疗项目进行的一项评价发现，虽然接受姑息治疗的病人对项目活动感到满意，但更广泛的贫民窟社区对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一个主要威胁。社区参与公共卫生至关重要，以确保调动更多的资源，增强社区的权能。我们的目标是发展一个创新的跨界跨学科伙伴关系，通过制定一个文化上适当和科学上合理的战略，通过“社区剧院”加强公众参与，为孟加拉国城市贫民窟姑息治疗项目的可持续性提供支持。社区剧场被认为是一种有效的方式，让社区成员参与持续的反思活动和美学实践，以帮助解决和反思社区关注的问题。将根据对当地社会和文化对死亡、临终和临终关怀做法的理解进行的人种学探索，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的社区剧院股提供便利。然后我们将评估他们的表现。参与这项试点活动的过程将被记录和拍摄，这些记录将用于评估学习成果，以及通过艺术制定公共卫生姑息治疗的社区参与战略。建立这种伙伴关系将为医学，人文，艺术和发展的研究人员和从业人员提供一个独特的机会，否则他们不会在孟加拉国一起工作，互动，并产生新的见解公共卫生姑息治疗，以及发展跨学科的研究能力。这种伙伴关系的经验将成为随后的资金申请的基础，以产生证据，证明孟加拉国及其他地区资源贫乏的环境中具有强大和文化敏感性的公共卫生姑息治疗。

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.