Training program on Orientation to “Health as a Human Right towards realizing 'Health for AH' ”
Item
- Title
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Training program on
Orientation to
“Health as a Human Right
towards realizing 'Health for AH' ”
- extracted text
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(
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C
' / J -
' r 'f
f
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Training program
on
Orientation to
“Health as a Human Right
towards realizing 'Health for AH' ”
)
4th and 5th February 2008
Bangalore
J
I
II
Community Health Cell
Society for Community Health Awareness, Research and Action
359, Srinivasa Nilaya, Jakkasandra 1st Main, 1st Block,
Koramangala ,Bangalore - 560 034.
Ph: 080-25531518 | Fax: 080-25525372
e-mail: chc@sochara.org Website: www.sochara.org
I
Orientation / Training Program on
“Health as a Human Right towards realizing Health for All
4-5 February 2008
1
CORE READING MATERIALS
CONTENTS
Particulars
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Session 1
Pages
j___________________________________________
1. Right to health and health care: Theoretical perspectives
1-16
2. Building on the Synergy between Health and Human Rights: A Global Perspective
17-26
3. Health & Human Rights'_____________________________________________
27-65
Session 2___________________________________________________________
1. The political economy of assault on health
66-75
2. Equity andjnequity- Some contributing social factors
76-80
3. Communication as if people mattered
81-102
4. Social inequalities in health within countries: not only an issue for affluent countries
103-118
Session 3___________________________________________________________
* 1. A Paradigm Shift From 'Charity' To 'Rights And Dignity' : A write-up based on the
119-120
United Nations Convention on the Rights of Persons with Disabilities (UNCRPD)
Session 4___________________________________________________________
1. Universal Declaration of Human Rights
121-126
127-136
2. International Covenant on Economic, Social & Cultural Rights (ICESCR)
3. General Comment 14 of ICESCR
137-159
160-169
4. People Charter for Health
170-175
5. Mumbai Declaration
176-177
6. People's Charter on HIV-AIDS
178-180
7. Alma-Ata Declaration
181-186
8. Constitutional & legal framework for right to health in India
9. Examples of international, regional and national instruments relevant to the right to
187-205
health____________________
Session 5___________________________________________________________
206-207
1. PHM Pamphlet
208
2. JSA Right to Healthcare Campaign: The right to Health Care is a basic Human Right!
3. Right to health care campaign - A campaign towards revitalization of public health
209-219
systems in Karnataka
220-222
4. Report on Karnataka State Level People's Health Action Day
223-226
5. Primary Health Care: An Experience
227-228
6. Novartis boycott campaign
7. National Rural Health Mission: A promise of better health care services for the poor
229-253
8. Taking action: Working with the right to health
254-272
9. The Assessment of The Right To Health And Health Care At The Country Level
273-313
314
10. List of Abbreviations
Note: The articles/written works are derived from various sources. The author's name can be
found in individual papers. We acknowledge with thanks the contribution of various authors in
disseminating and improving the knowledge on theory and practice of health and human rights.
Community Health Cell, Bangalore
Orientation/Training Program on “Health as a Human Right towards realizing Health for All”
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Session 1 Conceptual Framework of right to health and health care
Community Health Cell, Bangalore
9C
One
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Right to Health and Health Care
Theoretical Perspectives
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Ravi Duggal
Introduction
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in rural areas, and district and town hospitals and
dispensaries in urban areas. However, the
development approach was never rights-based and
hence the limited entitlements that were made
under different development programmes,
including healthcare, had a limited impact. The
contribution of the Five Year Plans to the social
sectors has been abysmally poor; less than onefifth of the Plan resources have been invested in
this sector. Health, water supply and education
are the three main sub-sectors under social services.
The Indian Constitution provides a framework for
a wclfare/socialiist .pattern of development. While
civil and political rights are enshrined as
Fundamental Rights that are justiciable, social and
economic rights’like health, education, livelihoods
etc. are provided for as Directive Principles for the
State and hence nj)t justiciable. The latter comes
under the domain of planned development, which
the State steers through the Five Year Plans and
other development policy initiatives.
Within the State’s development strategy the health
sector has always been a weak link. For the political
class it had little value because at one level the
private health sector, at least for non-catastrophic
care, was already well entrenched and was
reasonably accessible, and at another for the poor
masses non-catastrophic healthcare attention was
way below in their priority list, what with the
struggle for basic survival. The political class
invested in development where they could
maximize their political returns; their concern was
for vote-banks and hence the focus of development
programmes (not rights) was in ‘rural
development’, ‘infrastructure development’ and
development through ‘reservations’. Rural
development programmes helped direct
agricultural growth with t.he goal of achieving selfsufficiency in basic food production. In reality the
middle and the rich peasantry benefited and the
small peasantry and landless remained under the
illusion that their turn in development was next.
Infrastructure development helped create space
and conditions for their growth, and the reservation
policies appeased the oppressed minorities.
Post-independence India adopted a development
paradigm that aimed at creating limited
entitlements to a wide range of resources for the
underserved people. While this was critical to
India’s economic development it also contributed
substantially to the growth of private capital. The
State also actively participated in the productive
sectors of the economy, especially capital goods
industry. This often subsidized inputs for private
sector growth. In the social sector the approach
was not very different.
The development paradigm adopted by the political
leadership and the state had a social dimension,
but also supported private sector growth. To take
two examples, while private pharmaceutical
industry got a lot of subsidy and support for its
growth, drug price control helped keep the prices
on a leash. Similarly, while production of doctors
contributed largely to the development of private
markets in the health sector, the government
evolved a system of limited entitlements for
healthcare through a primary healthcare system
Healthcare Case Law in India
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Ravi Duggal
With this kind of a development strategy key social
development issues like health, eduction and
housing got sidelined and never became ’political
issues which would drive the development stratX
Planned development without a rights basTd
approach can only yield limited results and
immunization which the states have to implement,
n sum central government intervention in the
states domain of health care activities is an
important feature that needs to be considered in
any analysis of public health care services.
For issues to become
p itical agendas, they must be contextualised in
th rights domain. The right to health and
healthcare too cannot be realized through the
c 71 devel°pment agenda. It has Sto be
to7if U 4dtai 3n ,ndependent right, like the right
to life in Article 21 of the Constitution of India ; '
and/
or through a legislative mandate with clear
resource commitments.
Health Care System
The distribution of health care services is skewed
favouring urban areas. Large cities, depending on
tin T ^Opulatl°n have a few State- run hospitals
(including teaching hospitals). At the district level
on an average there is a i5o bedded Civil General
Hospital in the mam district town and a few smaller
hospital.
.
Is and dispensaries spread over the other
towns in the district and sometimes in large
hages. In the rural areas of the district there are
sub centSPltan ’ Primaiy health CentreS (PHCs) and
and’outr \
I-r°Vide Vari°US heaIth se™s
and outreach services.
The Constitution has made health
care services
largely a responsibility of State
governments
but For the country- as a whole presently there are an
has left enough manoeuvrability
for the Centre
d 22,000 h°spitals (30 per cent rural),
since a large number of items are listed in the S
11
’
mihin
pe"Sa.r,es (5° Per cent rural) and about
concurrent 1st. The Centre has been able to expand
■5
million
beds (2iper cent rural) (Table A). The
^ sphere of control over the health sector? Hence
the central government has played a far more mTooTsX11 additi°n have 23>5OO PHCs and
significant role in the health sector than demanded 140,000 sub-centres. However, when this data is
by the Constitution. The health policy and planning r'pres“ted proportionately to its population we
framework has been provided by the central see that urban areas have 4.48 hospitals, 6 16
dispensaries and 308 beds per 100,000 urban
government. In concrete terms, the central
oX111.'y3? C°ntraSt t0 rUral areas which
government has pushed various national have
programmes (vertical p-^iionai have •77 hospitals, 1.37 dispensaries, 3 2 PHCs
programmes for leprosy, and 44 beds pi
tuberculosis, blindness, i
malaria, smallpox,
diarrhoea,
filaria,' <-»
goitre
and no
-< . , _
—■*' ****'-1
now HIV/AIDS) in pZntX0611^5 Pr°Viding oul:Patient and inwhich the States have had little
-J say. The States
have acquiesced due to the central government’s care Tn
7 " T'™17’ SecondaiT and tertiaiy
accompanying funding. These proframmTs are care in contrast the rura] institutjons provi^
in y preventive and promotive services like
implemented uniformly across the length and
-rn-nicabU
disease control programmes^
breadth of the country. Then there are the Centre’s
own programmes of family planning and universal services rnilr Sei'ViCeS and immunization
services. Curative care in the rural health
' J.11* qonstitutional provisions (Schedule - '
includes^igina^
gOVe.rn ,but with the
s^nita^
latouV
24 ”
deluding/iXp-iTal
and
mental deficiency including Dhp3”6/ 9'^ellef of the disabled
of foodstuffs and^ther good! io n
reception
or treatment of lunatics and mAntd X L
16-Lunacy and
20A.Population control and 9‘ family5
P°iSOnS’ SUbjeCtt to the provisions of entrv
fi - e^lcients 18-Adulteration
3 23.Social
security and f social ’i^
* W'th reSpeCt t0 opium
- includmg conditions of work, provident funds
,ns“rance;
employment
and
age pensions and maternity benefits 25 Education Z 1
'^''^en’s
- - -provisions of entries 63 6a fie
a
teclln’cal education,
Legal, medical and other professions ^o.Vfia^stat",tie!
VOCational “""d
births and deaths, (http://alfa.nic
)n/const/schedule.html)
statistics including registration of
Healthcare Case Law in India
2
f Ravi Duggai
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__
institutions are the weakest component even
though, there exijsts a high demand for such
services. This demand is met either by the city
hospitals or by private practitioners.
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Medical education is imparted largely through
state-owned/funded institutions at highly
subsidized costs. There are 195 recognized
allopathic medical colleges in the country
producing over 20,000 medical graduates every
year 75 per cent of whom are from public
institutions. However, the outturn from these
institutions does not benefit the public health
services because 80 per cent of the outturn from
public medical schools either joins the private
sector or migrates abroad.
The private health sector in India is very large. In
2002 an estimated 62 per cent of hospitals, 54 per
cent dispensaries and 35 per cent of beds were in
the private sector (Table A). An estimated 75 per
cent of allopathic doctors are in the private sector
and about 80 per cent are individual practitioners.
Over 90 per cent of non-allopathic doctors work
in the private sector. Private health services,
especially the general practitioners, are the single
largest category of health care services utilized by
the people. There also exist a large number of
unqualified practitioners in urban and rural areas
in the private sector whose services are well
utilized, but their actual numbers are not known.
Available data show that in 2004 there were over
660,000 registered allopathic doctors and over
780,000 registered non-allopathic doctors. Of the
1.4 million doctors about 1.2 million are estimated
to be in the private sector.
circles in India. There is virtually no regulation of
this sector. The medical councils of the various
systems of medicine perform only the function of
registering qualified doctors and issuing them the
license to practice. There is no monitoring,
continuing education, price regulation,
prescription vetting etc., either by the medical
councils or the government. It has not been possible
to implement progressive policy initiatives, such
as the recommendation of the Hathi Committee
Report2 Pharmaceutical formulation production
in India is presently worth over Rs. 280 billion and
over 98 per cent of this is in the private sector.
How does all this impact on health outcomes,
especially among the poor? In Table A we see
substantial improvements in health outcomes such
as IMR, CBR, CDR and life expectancy over the
years. But India’s global rank vis-a-vis these
indicators has not changed. In fact the latest
Human Development Report shows a downward
trend in India’s global ranking.3
This slowing of growth in India’s human
development score is perhaps linked to the
declining investments and expenditures in the
public health sector (as also the social sectors as a
whole), especially in the 1990s. In the mid- 1980s
public health expenditure had peaked because of
the large expansion of the rural health
infrastructure but after 1986 one witnesses a
declining trend in both new investments as well as
expenditures as a proportion to the GDP, and as a
percent of government’s overall expenditures.
[Duggal et.al., 1995 and Duggal, 2002]. In sharp
contrast out-of-pocket expenses that go largely to
the private health sector, have witnessed
unprecedented increases. (See Table A)
The private health sector, especially the allopathic,
constitutes an influential lobby in policy-making
The Hathi Committee’s recommendations pertained to removal of irrational drug combinations, generic naming of
essential drugs and development of a National Formulary for prescription practice.
* India’s human development index rank is down from 115 in 1999 to 124 in 2000 and 127 in 2001, though still
better than the 1994 rank of 138. It is on the fringe of medium and low HDI group of countries. India’s improvement
in the HDI in the last 26 years has been marginal from a score of 0.407 in 1975 to 0.590 in 2001 - working out to an
average increase of 1.7 per cent per annum. The slowing down of growth is shown in the table below: [UNDP HDR,
various years]
HDI score
Annual % increase over previous period
Healthcare Case Law in India
1975
0.407
3
1980
1985
0.434
1.3
0.473
1.8
1990
0.511
1.6
1995
2000
0.545
1.3
0.577
1.1
Ravi Duggal
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Table Ai Health Care Development in India, 1951-2004
1951
1
2
Hospitals*
Hospital &
dispensary
beds*
3
Total
Per cent
Rural
Per cent
Private
Total
Per cent
Rural
Per cent
Private
Dispensaries*
Per cent
Rural
Per cent
Private
4
5
6
PHCs
Sub-centres
Doctors
2694
39
1961
3054
34
1971
1981
3862
32
6805
27
43
1991
11174
57
1 170(XJ 229634 348655 504538 806409
23
22
21
17
6600
79
725
9406
80
12180
78
1996
15170
68
1997
2001-02 Latest'''
15188
34
18436
22000
:io
30
68
62
75
8927*38 896767 914543
23
21
23
3__
28
32
37
37
16745
69
27431
25653
41
25670
40
22291
50
13
60
57
56
54*'
2695
1500000
21
50
; 35
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5131
5568
22243
27929 51192 131098
60840 83070 153000 266140 393640
156000 184606 450000 665340 920000
21917
134931
462745
16550
30
35584
80620
98
150399 311235
111
128
565700
60
Graduates
Postgrad
uates
1600
3400
397
10400
1396
12170
3833
13934
3139
Rs. in
0.2
0.8
3
14.3
38.4
billion
1MR/000
134
146
80
72
41.7
41.2
138
37.2
110
CBR/000
33.9
29.5
27
CDR/000
22.8
19
15
12.5
9.8
8.1
8
years
Percent
32.08
41.22
45.55
54.4
59.4
64.8
65
18.5
21.9
28.5
Public
0.22
50.78
101.65
113.13
211
249
82.61
329
373.41
1100
1464
Allopaths
AH
22446 22842
136379 137311
496941 605840
23500
140000
660000
108017$ 1297310 1430000
Systems
7
8
9
Nurses
Medical
colleges
Out turn
10
Pharmaceutical
production
11
Health
outcomes
Life Expectancy
Births attended
by trained
practitioners
12 Health
Expenditure
Rs. Billion
Health
Expenditure
as percent
of GDP
Health
Allopathy
cso
165
607376 805827
165
189
880000
195
20000
3656
91.3
104.9
6000
220
280
71
66
65
25
24
9
27
8.9
62.4
63.5
1.08
3.35
2.05
6.18
12.86
29.7
0.71
0.84
1.05
0.92
0.91
1.56
2.43
1.73
2.95
0.88
3
0.89
1.34
5.32
0.91
5.4
5.13
3.84
3.29
2.88
2.98
2.94
2.72
2.6
private
Public
Private
CSO
0.25
Public
2.69
Expenditure
as % to
Govt. Total
____
Healthcare Case Law in India
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Ravi Duggal
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2001-02 for public facilities also Ssuffe^f^
under sported and figures for
”"d
s
ates by author and figures pertain to years 2003/2004
Source . 1. Health Statistics / Information of India crht r'm
1961. 1971, 1981. GOI 3.OPPI Bulletins and Annua! reports o'f“
CenSUS °------------f
Ec0n0mlc
-wllwnuC Tables,
Min. of Chemicals
and Fertilisers for data on
sXXT’csO Go?UCtrtn 4' FlnanCe Accounts of Ccntral and State Governments
vstatistics, CSO, GOI, various years 6. Statistical Abstract nf Tnd<o
c“uucins- various years 5. National Accounts
Statistical Reports, various years 8. NFHS - 2, India Report, IIPS^OOO
3 7. Sample Registration System -
Human Right to Health and
Healthcare4
Fundamental Rights are justiciable, and on a
number of occasions citizens and courts have
intervened to uphold them, there have also been
Constitutional and Legal Dimensions
numerous instances where even the courts have
failed either because the ruling government has
India joined the UN at the start on October 30th steamrolled them or the court orders have been
1945 and on December 12th 1948 when the ignored. In case of the Directive Principles it is
Universal Declaration of Human Rights (UDHR) mostly political mileage, which determines which
was proclaimed, India was a party to this. The of the principles get addressed through
formulation of India s Constitution was certainly governance. For instance, Article 466 has been
influenced by the UDHR and this is reflected in implemented with a fair amount of seriousness
the Fundamental Rights and the Directive through the policy of reservations for scheduled
Principles of State Policy. Most of the civil and caste, tribes and other backward castes/classes
political rights are guaranteed under the Indian because it is the most powerful tool for success in
Constitution as Fundamental Rights. But most of India’s electoral politics. But Articles 41, 42 and
the Economic, Social and Cultural Rights do not 47> which deal with social security, maternity
have such a guarantee. The Constitution makes a benefits and health, respectively, have been
forceful appeal to the State through the Directive addressed only marginally.
Principles to work towards assuring these rights
through the process of governance but clearly When we look at right to health and healthcare in
states that any court cannot enforce them.5
the legal and constitutional framework, it is clearly
evident that the Constitution and laws of the land
The experience of governance in India shows that do not in any way accord health and healthcare
both Fundamental Rights and Directive Principles the status of rights. There are instances in case law
have been used as a political tool. While the where, for instance the right to life, Article 21 of
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The WHO definition was influenced largely
Sieerist £ « H a ♦kT
h!nCG they mUSt be seen in tandemsocial condition and “health is, therefore not simnlv the’absence gf^ h
s*— °f hea'th 'S a Physical> mental and
toward life, and a cheerful acceptance of the rtspon^bi^ es that 1
11 1Susome,thinB Positive, a joyful attitude
This broad definition, including'social well-being""often criticised ^“^1^ I 6 'h'’^
[SigeriSt’ 1941’ P-68L
concern for access to healthcare is lost. However Sigerist also
tJ8 J k ^r°ad and as a consequence the
was the right of the citizen and it was the state’s duty to resnect tHs ThP L
•
" p.rotection and Provision
Provisions con^nld^n Thil krt^hlll’Ztle^
in Par' IV °f the consti‘“tion states,
states, •“The
._ ---are
the — °f
princip,es
iaid
downathese
duty
of the therein
State to
apply
sel't?o^-4!h'ePsrtTpOtilOniIOf educationa! and economic interests of Scheduled
u.„cuuleu ,
Castes,
Scheduled
Tribes and other weaker
people, arn^
the ScSedT ‘b6
C -ti0?al
eCOn°miC
in‘ereS
‘S °(
j .1
01 , , , ------the weaker sections of
Castes and the Scheduled Tribes, and shall protect them from social
injustice and all forms of exploitation.
Healthcare Case: Law in India
Ravi Duggal
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To take an example, government polity vis-a-vis
healthcare services
services has mandated
mandated entitlements
made to the lltonSaTS^iantT' referenCeS SthiTT^has
NeedS Pr°Sr“ carted
with the Fourth Five Year -Plan. Each district
These are exceptional cases, and even if the should have a civil hospital in each district a
Supreme Court or the high courts have upheld Pomary health centre in rural areas for each
me decisions as being a right, for instance getti ng no t ?• -3?’000 Population (depending on
. least first aid in emergency situations froin population density and difficultv of terrain) uid
private clinics or hospitals, or access to public live such units supported by a 30 bedded
medical care as a right in life threatening Community Health Centre (CHC), a sub centre
situations, or right to healthy and safe working with two health workers for a rural population unit
environment and medical care for workers etCS pUT'cT0 P°pulation’ and similarly a Health
the orders are rarely respected in day to day practice • th/ 1 +0° ?erS°nS in Urban areas- But what
s the real situation? No district (except perhaps
unless one goes back to the courts to reiterate th!
orders. In fact, this is often the case even with
very new ones) has a civil hospital (and eadi
istnet id have a civil hospital even during the
Fundamental Rights, which the State has failed to
respect, protect, or fulfil as a routine, and one h2 varies^
The Situation regarding PHCs
varies
a
lot
across
states from 1 pfer 7000 rural
0 go to the courts to demand them For a population in Mizoram
to 1 per oler 100 000 in
population, which is predominantly at the poverty
some
d
,
st
j
ts
of
the
EAG7
pates The°°^« "
or subsistence level, expecting people to go to th!
Xln v th
CannOt 10
court*
“dafoed566’ JUStiue f°r What iS constifotionally
ordained as a right is unrealistic as well a! demanding the right to a PHC for their area
discriminatory. The mere constitutional provision FurthUSe
3 16831 backing d0es ^ot exist
and mo^016"' conditi°n to guarantef a right, for PHc^rZr3165 aVhere this ratl°is honoured
and more so in a situation like health and tor PHCs or CHCs, adequate staff, medicines
healthcare wherein provisions in the form of noTava5 lable t'tieS’ maintKenance budgets are often
services and commitment of vast resources are not avai able to assure that proper provision of
services is available to the people accessing Siese
necessary to fulfil the right.
mces MoHFW, 2ooi). Further still, if on! M
Despite the above, it is still important to have health nt distribution of healthcare resources across
and healthcare instituted as a right within the legions, iural and urban areas, one sees vast
Gonstitotion and/or established by a specific Act hellthh1 datlt°n in rnetroP°litan areas public
of Parliament guaranteeing the rigto Ruth health budgets range from Rs.500-1300 per canita
oemer discussing this issue writes, “The principal m sharp contrast to PHC areas with only ks 4/
aCr°SS the cou^^ have
S h! kh
COnStitutional provision for toe rgit a bePdtrnCnaP1T;Urban
o health care is usually symbolic. It sets forth toe
population ratio of over 300 beds ner
.00,000 population io c„ntrast (o "urai area
intention of the government to protect the health
i°s n!tCltl If"5'A Statement of national policy alone havtog around 40 beds per 100.000 persons Til
not sufficient to assure entitlement to health ca® help’aE afe''1'" “
tha(
care; the nght must be developed through sperifm
tl tUtem pr°grams and services. But setting forth
info^l
Care in 3 institution serves to Apart from the above a small privileged section of
nfo/m the people that protection of their health is sectPo0rPUthat°n’
iS Called the orga™ed
officml pohey of the government and is reflected sector, that is those working in government
m the basic law of the land”.
rertected heaWsTclal5^
haVe SOme form oi
th/social insurance coverage, either through
EAG stands for E.4
Pradesh, Uttaranchal*/
?OUP States --eh indude Rajasthan, Madhya Pradesh, Chattisgarh. Uttar
. tfihar, Jharkhand and Orissa
iealthcare Case Law in India
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Ravi Duggal
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social security legislation like Employee State (d) The creation of conditions, which would assure
Insurance Scheme, Central Government Health
to all medical service and medical attention in
Scheme, Maternity Benefit Scheme, and various
the event of sickness.
other schemes for mine workers, plantation
workers, beedi workers, cinema workers, seamen,
Also Ai tides 7 and 11 include health provisions:
armed forces, railway employees etc., or through
The States Parties ... recognize the right of
employer provided health services or
everyone
to ... just and favourable conditions of
reimbursements. This population estimated to be
work
which
ensure ... safe and healthy working
about 12 per cent of the country’s population might
conditions; ... the right to ... an adequate standard
be said to have right to healthcare, at least during
of living.”
the working life of the main earner in the family.
Another iper cent of the population is covered
through private health insurance like Mediclaim India ratified this Covenant on 10th April 1979, and
[Ellis, Randal et.al, 2000]. In these cases having done that became obligated to take
entitlement is based on employment of a certain measures to assure health and healthcare (among
kind, which provides rights on the basis of others) as a right. As per Articles 2 and 3 of this
protective legislation that is not available to the covenant States ratifying this treaty are obligated to:
general population. While this is a positive
provision, it becomes discriminatory because the Article 2
entitlement as a right is selective and not universal. 1. Each State Party to the present Covenant
undertakes to take steps, individually and
Mere entitlements having basis only in policy or
through
international assistance and co
as selective rights does not establish a right and
operation, especially economic and technical,
neither can assure equity and non-discrimination.
to the maximum of its available resources,
with a view to achieving progressively the full
At the global level the International Covenant on
realization of the rights recognized in the
Economic, Social and Cultural Rights (ICESCR)
mandates right to health through Article 9 and
present Covenant by all appropriate means,
Article 12 of the covenant:
including particularly the adoption of legislative
measures.
2. The States Parties to the present Covenant
Article 9
The States Parties to the present Covenant
undertake to guarantee that the rights
recognize the right of everyone to social security,
enunciated in the present Covenant will be
including social insurance.
exercised without discrimination of any kind
as to race, colour, sex, language, religion,
Article 12
political or other opinion, national or social
1. The States Parties to the present Covenant
origin, property, birth or other status.
recognise the right of everyone to the 3- Developing countries, with due regard to
enjoyment of the highest attainable standard
human rights and their national-economy,
of physical jmd mental health.
may determine to what extent they would
2. The steps to' be taken by the States Parties to
guarantee the economic rights recognized in
the present Covenant to achieve the full
the present Covenant to non-nationals.
realization of this right' shall include those
necessary for:
Article 3
(a) The provision for the reduction of the stillbirth The States Parties to the present Covenant
rate and of infant mortality and for the healthy undertake to ensure the equal right of men and
development of the child;
women to the enjoyment of all economic, social
(b) The improvement of all aspects of
and cultural rights set forth in the present
environmental and industrial hygiene;
Covenant.
(c) The prevention, treatment and control of
epidemic, endemic, occupational and other
It is now over 25 years since India committed to
diseases;
this treaty. Post-ratification efforts through the
I
1
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Sixth Five-year Plan and the first National Health
Policy in 1982 were indeed the first steps in
honouring this commitment. As we have seen
above, the rural public health infrastructure was
expanded considerably during the first half of the
’Eighties, more resources were being committed
to the health sector etc., but somewhere by the
mid- Eighties the commitment seems to have lost
ground. In the 1990s with the economic crises the
public health sector lost out completely, with the
final blow being delivered by the National Health
Policy 2001. Interestingly, the last decade of the
20th century also saw the declining commitment
to Health For All by the WHO, when in the 1998
World Health Assembly it announced its policy for
Health for All in the 21st Century. WHO had started
toeing the World Bank line from the 1993 World
Development Report (WDR) Investing in Health,
which asked poor country/developing country
governments to focus on committing public
resources to selective care for selected/targeted
populations, and to leave the rest to the market.
With inter-governmental commitment to assure
the right to the highest attainable standard of
health waning, it became even more difficult for
the Indian State to honour its commitment to
ICESCR in an economic environment largely
dictated by the World Bank. At another level the
Committee of the Economic, Social and Cultural
Rights, which is supposed to monitor the
implementation of ICESCR, has also failed to get
countries like India to take measures to implement
the provisions of the ICESCR. India has submitted
its combine 2nd, 3rd, 4th & 5"> periodic report to UN
in October 2006.8
as well as relate to many policy initiatives taken
within the country.9
Health is a state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity. The
enjoyment of the highest attainable standard
of health is one of the fundamental rights of
every human being without distinction of
race, religion, and political belief, economic
or social condition. The health of all peoples
is fundamental to the attainment of peace
and security and is dependent upon the fullest
co-operation of individuals and States. The
achievement of any State in the promotion
and protection of health is of value to all.
Unequal development in different countries
in the promotion of health and control of
disease, especially communicable disease, is
a common danger. Healthy development of
the child is of basic importance; the ability to
live harmoniously in a changing total
environment is essential to such
development. The extension to all peoples of
the benefits of medical, psychological and
related knowledge is essential to the fullest
attainment of health. Informed opinion and
active co-operation on the part of the public
are of the utmost importance in the
improvement of the health of the people.
Governments have a responsibility for the
health of their peoples, which can be fulfilled
only by the provision of adequate health and
social measures. - WHO Constitution
I
“Everyone has the right to a standard of living
adequate for ... health and well-being of
himself and his family, including food,
clothing, housing, medical care and the right
to security in the event of ... sickness,
disability.... Motherhood and childhood are
Following are other international laws, treaties and
declarations, which India is a party to and which
have a bearing on the right to health. Provisions
in most of these also relate to Fundamental Rights
and Directive Principles of the Indian Constitution
The report is available at httpi/ /www,ohchr.org
9 For instance, the impact of CEDAW, Cairo and Beijing Declarations is closely linked to the formulation of1 a oolicv on
MahHa
and r‘ting UP °f the natiOnal and stale Commissions on Women the Rashtriya
SirniHrlv dth f formulat'on of man{ development programs for women like DWACRA, savings and credit programs
etc. S milar y the various human rights treaties like those dealing with racial discriminatfon torture civil and
ComXsions TheCNHRChhas
HR J,aVe ,been lnstr«m<-‘ntal in India setting up the National and State Hu‘?an Rights
Commissions. The NHRC has presently set up a separate cell to monitor ICESCR as also for right to public health8
Healthcare Case Law in India
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entitled to special care and assistance....” Universal Declaration of Human
Rights, Article 25
18 No. 4, 1992, 302). At the International
conference which followed in 1978 at Alma
Ata this was converted into the famous
primary health care declaration whereby
Governments would be responsible to the
people to assure primary health care for all
by the year 2000. Primary health care is
essential health care which is to be
universally accessible to individuals and
families in the community in ways acceptable
to them, through their full participation at a
cost the community can afford” (WHO,
Primary Health Care, 1978, p. 3) - Alma
Ata Declaration on Health For All by
“States Parties shall ... ensure to [women] ...
access to specific educational information to
help to ensure the health and well-being of
families, including information and advice
on family planning.... States Parties shall ...
eliminate discrimination against women in
... health care
to ensure, on a basis of
equality of men and women, access to health
care services, including those related to family
planning...., ensure ... appropriate services in
connection with pregnancy.... States Parties
shall... ensure ... that [women in rural areas]
... have access to adequate health care
facilities, including information counselling
and services in family planning....” Convention on the Elimination of All
Forms of Discrimination Against
Women, Articles 10, 12, and 14
2000
Health and development are intimately
interconnected.
Both
insufficient
development leading to poverty and
inappropriate development ... can result in
severe environmental health problems.... The
primary health needs of the world’s
population ... are integral to the achievement
of the goals of sustainable development and
primary environmental care.... Major goals
... By the year 2000 ... eliminate guinea worm
disease...; eradicate polio... By 1995 - reduce
measles deaths by 95 per cent...; ensure
universal access to safe drinking water and
... sanitary measures of excreta disposal...;
By the year 2000 [reduce] the number of
deaths from childhood diarrhoea ... by 50 to
70 per cent...” - Agenda 21,Chapter 6,
paras. 1 and 12
“States Parties undertake to ... eliminate
racial discrimination ... and'to guarantee the
right of everyone, without distinction as to
lace, colour, 01 national or ethnic origin, to
equality before the law, ... the right to public
health, medical care, social security and
social services....” -Convention on the
Elimination of All Forms of Racial
Discrimination, Article 5
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“States Parties recognize the right of the child
to the enjoyment of the highest attainable
standard of health and to facilities for the
treatment of illness and rehabilitation of
health. ..” - Convention on the Rights of
the Child, Article 24
Everyone has the right to the enjoyment of
the highest attainable standard of physical
and mental health. States should take all
appropriate measures to ensure, on a basis
of equality of men and women, universal
access to health-care services, including those
related to reproductive health care.... The role
of women as primary custodians of family
health should be recognized and supported.
Access to basic health care, expanded health
education, the availability of simple costeffective remedies ... should be provided....”
- Cairo Programme ofAction, Principle
8 and para. 8.6
In the 1977 World Health Assembly member
states pledged a commitment towards a
health for all strategy, “... the attainment by
all citizens of the world by the year 2000 of a
level of health that will permit them to lead
a socially and economically productive life...”
(AL Taylor -Making the World Health
Organisation Work : A legal framework for
universal access to the conditions for Health,
American Journal of Law and Medicine, Vol
Healthcare Case Law in India
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Ravi Duggal
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“We commit ourselves to promoting and
attaining the goals of universal and equitable
access to ... the highest attainable standard
of physical and mental health, and the access
of all to primary health care, making
particular efforts to rectify inequalities
relating to social conditions and without
distinction as to race, national origin, gender,
age or disability....” - Copenhagen
Declaration, Commitment 6
particularly primary health care, in order to
ensure universal access to health services...;
reduce maternal mortality by at least 50 per
cent of the 1990 levels by the year 2000 and
a further one half by the year 2015;... make
reproductive health care accessible ... to all
... no later than ... 2015...; take specific
measures for closing the gender gaps in
morbidity and mortality where girls are
disadvantaged, while achieving ... by the year
2000, the reduction of mortality rates of
infants and children under five ... by one third
of the 1990 level...; by the year 2015 an infant
morality rate below 35 per 1,000 live births....
Ensure the availability of and universal access
to safe drinking water and sanitation....” Beijing Platform for Action, para. 106
"The explicit recognition ... of the right of all
women to control all aspects of their health,
in particular their own fertility, is basic to
their empowerment.... We are determined to
... ensure equal access to and equal treatment
of women and men in ... health care and
enhance women’s sexual and reproductive
health as well as Health.” - Beijing
Declaration, paras. 17 and 30
'c
“Human health and quality of life are at the
centre of the effort to develop sustainable
human settlements. We ... commit ourselves
to ... the goals of universal and equal access
to ... the highest attainable standard of
physical, mental and environmental health,
and the equal access of all to primary health
care, making particular efforts to rectify
inequalities relating to social and economic
conditions ..., without distinction as to race,
national origin, gender, age, or.disability.’
Good health throughout the life span of every
man and woman, good health for every child
... are fundamental to ensuring that1 people
of all ages are able to ... participate fully in
the social, economic and political processes
of human settlements.... Sustainable human
settlements depend on... policies... to provide
access to food and nutrition, safe drinking
water, sanitation, and universal access to the
widest range of primary health-care
services...; to eradicate major diseases that
take a heavy toll of human lives', particularly
childhood diseases; to create safe places to
work and live; and to protect the
environment.... Measures to prevent ill health
and disease are as important as the availability
of appropriate medical treatment and care.
It is therefore essential to take a holistic
approach to health, whereby both prevention
and care are placed within the context of
environmental policy....” - Habitat Agenda,
paras. 36 and 128
“Women have the right to the enjoyment of
the highest attainable standard of physical
and mental health. The enjoyment of this
right is vital to their life and well-being and
their ability to participate in all areas of public
and private life.... Women’s health involves
their emotional, social and physical well
being and is determined by the social, political
and economic context of their lives, as well
as by biology.... To attain optimal health ...
equality, including the sharing of family
responsibilities, development and peace are
necessary conditions.” - Beijing Platform
for Action, para. 89
“Strategic objective ... Increase women’s
access throughout the life cycles to
appropriate, affordable and quality health
care, information and related services....
Actions to be taken: ... Reaffirm the right to
the enjoyment of the highest attainable
standards of physical and mental health,
protect and promote the attainment of this
right for women and girls and incorporate it
in national legislation...; Provide more
accessible, available and affordable primary
health care services of high quality, including
sexual and reproductive health care...;
Strengthen and reorient health services’
Healthcare Case Law in India
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P1
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International law apart, as discussed earlier,
provisions within the Indian Constitution itself exist
to give the people of India right to healthcare.
Articles 41, 42 and 47 of the Directive Principles10
enshrined in Part IV of the Constitution provide
the basis to evolve right to health and healthcare:
i
Article 41. Right to work, to education and to
public assistance in certain cases: The State shall,
within the limits of its economic capacity and
development, make effective provision for
securing the right to work, to education and to
public assistance in cases of unemployment, old
age, sickness and disablement, and in other cases
of undeserved want.
Article 42. Provision for just and humane
conditions of work and maternity relief: The State
shall make provision for securing just and humane
conditions of work and for maternity relief.
!
Article 47.’ Duty of the State to raise the level of
nutrition and the standard of living and to improve
public health: j’he State shall regard the raising of
the level of nutrition and the standard of living of
its people and the improvement of public health
as among its primary duties and, in particular, the
State shall endeavour to bring about prohibition
of the consumption except for medicinal purposes
of intoxicating drinks and of drugs which are
injurious to health.
Thus social security, social insurance, decent
standard of living, and public health coupled with
the policy statements over the years, which in a
sense constitutes the interpretation of these
constitutional provisions, and supported by
international legal commitments, form the basis
to develop right to health and healthcare in India.
The only legal/constitutional principle missing is
the principle of justiciability. In the case of
education the 93rd amendment to the Constitution
has provided limited justiciability. With regard to
healthcare there is even a greater need to make
such gains because often in the case of health it is
a question of life and death. As stated earlier, for a
small part of the working population right to
healthcare through the social security/social
insurance route exists. This means that such
security can be made available to the general
population too. That a few people enjoy this
privilege is also a sign of discrimination and
inequity that violates not only the non
discrimination principle of international law, but
it also violates Article 14 of the Constitution, Right
to Equality, under the chapter of Fundamental
Rights.
With regard to the question of justiciability of
international law, like Britain, India follows the
principle of dualism. This means that for
international law to be applicable in India, it needs
to be separately legislated. Since none of the
international human rights treaties have been
incorporated or transformed into domestic laws in
India, they have only an evocative significance and
may be used by the Courts or petitioners to derive
inspiration [Nariman, 1995]- Thus on a number
of occasions many of these human right treaties
ratified in India, have been used by the Indian
Courts in conjunction with Fundamental Rights.11
International law has its importance in providing
many principles but in India’s case, there is
substantial leeway within our own legal framework
on right to health and healthcare. The emphasis
needs to shift to critical principles as laid down in
the directive principles. This is the only way of
bringing right to health and healthcare on the
national agenda, even as the support of
international treaties wiH play a role in cementing
this demand.
==3===^
extension of fundamentaf rlgbtl m
an.,lnSt™ment
determine the extent of public Interest tn order to limit the
which m other clrcumXnc^may Seen^S.-^92)
°f PUbUC
theSupremTcourtoutTned
thfe„W°rk P?Ce' *n WhiCh the CEDAW and BelJlng Declaration was invoked,
rights and in harmnn
Hih 7?1 approach as follows - Any international convention not inconsistent with the fundamental
I^motrthe o^omhTconsmwionn?^^
rvT
P™510"5 t0 enlarge
meanlng and eonten“of to
quoted in Toebes, 1998)
Healthcare Case Law in India
g
n et (Vishaka v/s statc of Rajasthan, writ petition number 666-70 of 1992,
11
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Ravi Duggal
in
I
Framework for Right to Health and
Healthcare
discrimination, within the jurisdiction of the State
party. Accessibility has four overlapping,
dimensions:
Health and health care is now b.eing viewed very
much within the rights perspective and this is Non-discnmination-.heakh facilities, goods and
reflected in Article 12 ‘The right to the highest sei-yicesjnust be accessible to all, especially the
attainable standard of health’ of the International most vulnerable
-------- or marginalized sections of the
Covenant on Economic, Social and Cultural Rights
l’oPnlation, in
i law and in fad, without
According to the General Comment 14 the discrimination
discr>mination <on arny of the prohibited grounds.
Committee for Economic, Social and Cultural
Rights states that the right to health requires Physical accessibility, health facilities, goods and
availability accessibility, acceptability,
and quality
-------i----- j seiyces must be within safe physical reach for all
with regard to both health care and underlying sectl°ns of the population, especially vulnerable or
preconditions of health. The Committee^
LC.
Jmmittee interprets
majrSlnahzed groups, such as ethnic minorities and
the right to health, as defined inn Article
12
1 as an ‘nd'genous populations, women, children,
Article 12.1,
inclusive right extending not <only
‘ to timely and ad°lescents, older persons, persons with disabilities
appropriate health care L_.
but _also to the underlying and Persons with HIV/AIDS. Accessibility also
determinants of health, such as access to safe and implies that medical services and underlying
determinants
of health, such as safe aand potable
potable water and adequate sanitation an ucleirain
ants ot
adequate supply of safe food, nutrition and housing water
and
adequate
sanitation
facilities
r r .
------ are v\nthin
healthy occupational and environmental 1At[e.J^Pt1S1Caz- re,ach’. incIuding in rural areas.
conditions, and access to health-related education ^cciejssiblllt
>- further —includes
adequate
,
•"
■
del t_e access to
and information, including on sexual and buildings''"
----------------for persons with disabilities.
bdow
h’ ThiS understandinSis detailed
Economic accessibility (affordability): health
iaciiities, goods and sendees must be affordable for
The right to health in all its forms and at all levels a . Payment for health-care services, as well as
contains the following interrelated and essential services related to the underlying determinants of
elements, the precise application of which will health, has to be based on the principle of equity
depend on the conditions prevailing in a particular ensuring that these services, whether privately or
btate party:
publicly provided, are affordable for all, including
socially disadvantaged groups. Equity demands
(a) Availability. Functioning public health and that poorer households should not be
health-care facilities, goods and services, as well disproportionately burdened with health expenses
as programmes, have to be available in sufficient as compared to richer households.
quanthy within the State party. The precise nature
of the facilities, goods and services will vary Information accessibility: accessibility includes the
depending on numerous factors, including the right to seek, receive and impart information and
ideas concerning health issues. However
State party s developmental level. They will include
accessibihty
of information should not impair the
owever, the underlying determinants of health’
right
to
have
personal health data treated with
such as safe and potable drinking water and
confidentiality.
fuedities,-hospitals, clinics and
professional personnel Teleivi^d^Sticaliy settees
hea’th facilities’ 8oods and
competitive salaries, and essential drugs as defined
W ...e WHO Action P„e <fn Bssentild
culturallv L
^e®pe.Ctful of medical ethics and
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(b) Accessibility. Health facilities, goods and
services have to be accessible to everyone without
communities, sensitive to gender and life-cycle
Sdenfiah^n^11 being desjSned to resP«'t
those comeSd
StatUS °f
Healthcare Case Law in India
Ravi Duggal
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(d) Quality. As well as being culturally acceptable,
health facilities, goods and services must also be
scientifically and medically appropriate and of good
quality. This, requires, inter alia, skilled medical
personnel, scientifically approved and unexpired
drugs and hospital equipment, safe and potable
water, and adequate sanitation. (Committee on
Economic, Social and Cultural Rights Twentysecond session 25 April-12 May 2000)
I
(a) To ensure the right of access to health facilities,
goods and services on a non-discriminatory
basis, especially for vulnerable or marginalized
groups;
(b) To ensure access to the minimum essential food
which is nutritionally adequate and safe, to
ensure freedom from hunger to everyone(c) To ensure access to basic shelter, housing and
sanitation, and an adequate supply of safe and
potable water;
Cd) To provide essential drugs, as from time to time
defined under the WHO Action Programme on
Essential Drugs;
Ce) To ensure equitable distribution of all health
facilities, goods and services;
(f) To adopt and implement a national public
health strategy and plan of action, on the basis
of epidemiological evidence, addressing the
health concerns of the whole population; the
strategy and plan of action shall be devised’ and
periodically reviewed, on the basis of a
participatory and transparent process; they
shall include methods, such as right to health
indicators and benchmarks, by which progress
can be closely monitored; the process by which
the strategy and plan of action are devised, as
well as their content, shall give particular
attention to all vulnerable or marginalized
groups.
Uiiiveisal access to good quality healthcare
equitably is the key element at the core of this
understanding of right to health and healthcare.
. I o make this possible the State parties are obligated
to respect, protect and fulfill the above in a
progressive manner:
The light to health, like all human rights, imposes
tin ee types or levels of obligations on States parties:
the obligations to respect protect and fulfil. In turn^
the obligation to fulfil contains obligations to
facilitate, provide and promote. The obligation to
respect requires States to refrain from interfering
directly or indirectly with the enjoyment of the
right to health. The obligation to protect requires
States to take measures that prevent third parties
from interfering with article 12 guarantees. Finally,
the obligation to fulfil requires States to adopt
appropriate legislative, administrative, budgetary,
judicial, promotional and other measures towards
the full realization of the right to health. (Ibid)
The Committee also confirms that the following
are obligations of comparable priority:
(a) To ensure reproductive, maternal (pre-natal as
well as post-natal) and child
_________
health care;
To Provide immunization against the major
—
’•
infectious- diseases
occurring in the
community;
(c) To take measures to prevent, treat and control
epidemic and endemic diseases;
To Provide education and access to information
concerning the main health problems in the
community, including methods of preventing
and controlling them;
(e) To provide appropriate training for health
personnel, including education on health and
human rights. (Ibid)
States parties are referred to the Alma-Ata
Declaration, which proclaims that the existing
gross inequality in the health status of the people,
particularly between developed and developing
countries, as well as within countries, is politically,
socially and economically unacceptable and is,’
therefore, of common concern to all countries’
States
have a core obligation
to^ensure
the
. parties
.
—o--------aa^vaa^ mV
satisfaction of, at the very least, minimum essential
^
veIs of ea
ch of the rights enunciated in the
levels
each
covenant, including essential primary health1 care.
care,
cad in conjunction with more contemporary
— :Ii as the Programme of Action of
instruments, such
thee International
nternational Conference
Conference on
on Population
Population and
and
Development,
evelopment, the Alma-Ata Declaration provides
compelling guidance on the core obligations arising
from
* _
t
_
0
from article, 12 . Accordingly,
in the Committee’s
view, these core c_„
c
obligations
include at least the
following obligations:
Healthcare Case Law in India
The above guidelines from General Comment 14
on Article 12 of ICESCR are critical to the
development of the framework for right to health
13
13
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Ravi Duggal
and healthcare. As a reminder it is important to
emphasise that in the Bhore Committee report of
1946 we already had these guidelines, though they
were not in the ‘rights’ language. Thus within the
country’s own policy framework all this has been
available as guiding principles for now 60 years.
Where does India stand today vis-a-vis the core
principles of availability, accessibility, acceptability
and quality in terms of the State’s obligation to
respect, protect and fulfil?
To sum up from the earlier section, healthcare
infrastructure, except perhaps availability of
doctors and drugs is grossly inadequate. Then there
are the underlying conditions of health and access
to factors that determine this, which are equally
important in a rights perspective. Given the high
level of poverty and even a lower level of public
sector participation in most of these factors, the
question of the State respecting, protecting and
fulfilling them is quite remote.
Besides this environmental health conditions in
both rural and urban areas are quite poor, working
conditions in most work situations, including many
organized sector units, which are governed by
various social security provisions, are unhealthy
and unsafe. In fact, most of the court cases using
Article 21 of the Fundamental Rights and relating
it to right to health have been cases dealing with
working conditions at the workplace, workers
lights to healthcare and environmental health
related to pollution these will be dealt with in the
following chapters.
Other concerns in access are the question of
economic accessibility. It is astounding that largescale poverty' and predominance of private sector
in healthcare co-exist. This contradiction reflects
the State’s failure to respect, protect and fulfil its
obligations by letting vast inequities in access to
healthcare and vast disparities in health indicators,
to continue to persist, and in many situations get
worse. Data shows that out of pocket expenses
account for over 4 per cent of the GDP as against
only 0.9 per cent of GDP expended by state
agencies, and the poorer classes contribute a
disproportionately higher amouipjof their incomes
to access health care sendees both in the private
sector and public sector [Ellis, et.al, 2000; Duggal,
2000; Peters et.al. 2002]. Further, the better off
classes use public hospitals in much larger numbers
with their hospitalization rate being six times
higher than the poorest classes;*2 and as a
consequence consume an estimated over three
times more of public hospital resources than the
poor [NSS-1996; Peters et.al. 2002].
Related to the above is another concern vis-a-vis
international human rights conventions’ stance on
matters with regard to provision of services. All
conventions talk about affordability and never
mention free of charge sendees. In the context of
poverty this notion is questionable as far as
provisions for social security like health, education
and housing go. Access to these factors socially has
unequivocal consequences for equity, even in the
absence of income equity. Free services are viewed
negatively in global debate, especially since we have
had a unipolar world, because it is deemed to be
disrespect to individual responsibility with regard
to their healthcare [Toebes, 1998, p.249]. For
instance in India there is great pressure on public
health systems to introduce or enhance user fees,
in the belief that they will enhance responsibility
of the public health system and make it more
efficient [Peters, et. al.]. In many states that have
.
adopted
such a policy the immediate adverse
i
impacts are seen, the most prominent being
decline in utilization of public services by the
poorest. It is unfortunate that the Tenth Five Year
Plan draft document supports raising more
uY muicciiiiiE
resources by increasing user charges in secondary
and tertiary hospitals
/ 1
India’s taxation policy
favours the richer classes. Direct tax revenues, like
income tax is a very small proportion of total tax
revenues. Hence the poor end up paying a larger
proportion of their income as tax revenues in the
form of sales tax, excise duties etc. on goods and
services they consume. Viewed from this
perspective the poor have already pre-paid for
receiving public goods like health and education
fiom the state free of cost at the point of provision.
12 The poorer classes have reported
such low rates of hospitalization, not 1
.
because
fall ill
less often
lack resources to access ,healthcare,
and hence invariably postpone utilization
of they
hospital
servic'es
”undfbut
it' because they
unavoidable.
is absolutely
Healthcare Case Law in India
‘.ika
14
Ravi Duggal
IHSIgibr
I
So their burden ol inequity increases substantially
if they have to pay for such services when
accessing from the public domain.
The above inequity in access gets reflected in health
outcomes, which too, reflect strong class gradients.
In India there is an additional dimension to this
inequity — differences in health outcomes and
access by social groups, specifically the scheduled
castes and scheduled tribes. Data show that these
two groups are worse off than others on all counts.
Ihus in access to hospital care as per NSS 1996
data the STs had 12 times less access in rural areas
and 27 times less in urban areas than others; for
SCs the disparity was four and nine times, in rural
and urban areas, respectively. They fare worse even
in urban areas where overall physical access is
reasonably good. Their health outcomes 1.5 times
more adverse than others [NFHS 1998].
Another stumbling block in meeting state
obligations is information access. While data on
public health services, with all its limitations, is
available, data on and from the private sector is
conspicuous by its absence. For one, the size of the
private sector is an under-estimate as occasional
studies have shown.1* Medical councils of all
systems of medicine are statutory bodies but they
have been unable to regulate medical practice and
prevent unqualified.and untrained practitioners.
The private sector does not meet its obligations to
supply data on notifiable, mostly communicable,
diseases, which is mandated by law adversely
affecting the epidemiological database for those
diseases as also public health practice and
monitoring drastically.
policy with urban areas enjoying comprehensive
healthcare services through public hospitals and
dispensaries and now, preventive inputs and in
contrast rural areas with poor curative services.
This violates the principle of non-discrimination
and equity and hence is a major ethical concern to
be addressed.
Medical practice, especially private, suffers from a
complete absence of ethics. There has been poor
regulation of malpractices in medical practice.
There exist no standard protocols for clinical
practice making the monitoring of quality difficult.
For hospitals the Bureau of Indian Standards has
developed guidelines, and often public hospitals do
follow these guidelines [Nandraj and Duggal,
19971- But in the case of private hospitals they are
generally ignored. Recently efforts at developing
accreditation systems has been started in Mumbai
[Nandraj, et.al, 2000],and on the basis of that
the Central government is considering measures
al the national level on this
front1 so
so that
it can
----------that it
Prornote quality of care. The pharmaceutical
mdustry PlaVs a major role in encouraging
irrational
UTatlonal practices.
Practices.151*
References
1.
I
Finally there are issues pertaining to acceptability
and quality. Here the Indian state fails totally.
There is a clear rural-urban dichotomy in health
2.
Andreassen, B, Smith, A and Stokke, H,
(1992): Compliance with economic and Social
Rights: Realistic Evaluations and Monitoring
in the Light of Immediate Obligations in A
Eide and B Hagtvet (eds) Human Rights in
Perspective: A Global Assessment, Blackwell,
Oxford
Bhore, Joseph,(1946) : Report of the Health
Survey and Development Committee, Volume
I to IV, Govt, of India, Delhi
1994 showed that the official list lC
with a?
thee M-ic^>,COirporation accounted for only 64Per
nursing homes
[Nandraj
and
in I993 revealed exUaordinary
m s±
sta ist
cs Duggal,
bou 1 h,971mUCh la,^r s,ud>' in A"^a
traordinary missing statistics about the
records indicated that AP had 266 private hospitals and 11 iL Bp/ \
h SeCt°r- F°r that *ear official
J ar,
d 11,103with
beds,
strength of the private sector was over ten times^ore
hospitals
a F but
Ut the ®urvey .revealed that the actual
cent
.1
'"n.M^arcEHATj^I^ V2*92
Ho-Xl bX'^t^r^T ^f02
h°Spita’S a"d "aa^
non-profit company calledH^tV'c"™'L^i'tioT^
h°SpitaI °Wner -relations has set up a
larger initiative on this front.
Accred.tatton Counc.I. It hopes to provide the basis for evolving a much
value was to the tune lfdRUs8S2'.861 ^illil^A^tidy ofPnres6"'
outright irrational drugs constituted 45per'etnt of all druvs nr
irrational and/or hazardous and their
1P?'"0! ln .Maharashtra in 1993 revealed that
only iSper
Healthcare Case-. Law in India
15
IC
Ravi Duggal
-W* 'W
Sector, Radical Journal of Health (New Series)
II-2/3
'
!
17- Nariman, Fi(1995): Economic Social ami
Cultural Rights and the Role of lawyers, ICJ
4Review No. 55, 1995
18. NFHS-1998 (2000): National Family Health
Survey -2: India, UPS, Muiribai
19- NHP-2001: Draft National .Health Policy,
5Ministry of Health and Family Welfare, HOI.
New Delhi
20. NSS-1987 : Morbidity and Utilisation, of
^995
T , ,
Medical Services, 42nd Round, Report No. 384,
6. Duggal, Ravi (2000): The Private Health
National Sample Survey Organisation, New
Sector in India - Nature, Trends and a
Critique, VHAI, New Delhi
Delhi
NSS-1996
(2000) : Report No. 441, 52nd
Ellis,
Randall,
Alam,
Moneer
and
Gupta,
21.
7Indrani (2000): Health Insurance in India Round, NSSO, New Delhi, 2000
Prognosis and Prospectus, Economic and 22. OECD (1990) : Health Systems in Transition,
Organisation for Economic Cooperation and
Political Weekly, Jan.22, 2000
pyp
I
IX,
various
years:
Five
Year
Plans
Development, Paris
8.
First to Ninth, Planning Commission, GOI, 23- Phadke, Anant (1998): Drug Supply and Use
- Towards a Rational Policy in India, Sage,
New Delhi
Gupta,
RB
et.al.(1992)
■
Baseline
Survey
in
New Delhi
9Himachal Pradesh under IPP VI and VII, 3 24. Rhode, John and Vishwanathan, H (1994):
Vols.,
Indian Institute of Health
The Rural Private Practitionero, Health for the
Management Research, Jaipur
Millions, 2:1, 1994
io Hathi Committee, 1975: Committee of Drugs 25- Sigerist, H (1941): Medicine and Human
and Pharmaceutical Industry, Ministry of
Welfare, Oxford Univ. Press, London
Chemicals and Petroleum, GOI, New Delhi
26. Simon Commitlee (i960): National Waler
11. Hernan L. Fuenzalida-Puelma/Susan Schollc
Supply and Sanitation Committee, G01, New
Connor, eds (1989): The Right to Health in
Delhi
the Americas Pan-American Health
Toebcs,
Brigit (1998): The Right to Health as
Organization, Scientific Publication No. 509, 27- a Human Right in International Law,
Washington, D.C’
Intersentia - Hart, Antwerp
12 ICMR (1990): A National Collaborative Study
28. UNDP (2003): Human Development Report
of High Risk Families - ICMR Task Force,
2002, UNDP, NY (also years 1990-2001)
New Delhi
29- WHO, 1988 : Country Profile - India, WHO 13- MoCF (2001): Annual report, Dept, of
SEARO, New Delhi
Chemicals and Petrochemicals, Ministrof
WHO,
1988 a: Health Legislation, regional
30.
Chemicals and Fertilizers, GOI, New Delhi
office of Europe, WHO, Copenhagen
14 MoHFW (1983) : National Health Policy, 31. WHO,1993: Third Monitoring of Progress,
Govt, of India, Ministry of Health & Family
Common
Framework,
CFM3,
Welfare, New Delhi
Implementation of Strategies for Health for
15. MoHFW (2001): India Facility Survey Phase
All
by the Year 2000, WHO, Geneva,
I, 1999, UPS, Ministry of Health and Family
World
Bank, 1993: World Development
32.
Welfare, New Delhi
Report 1993: Investing in Health, Oxford
16. Nandraj, Sunil and Ravi Duggal (1997) ■
University Press, New York
Physical Standards in the Private Health
3-
CBHI, various years : Health Information of
India, Central Bureau of Health Intelligence,
MoHF&W, GOI, New Delhi
De Villiers (1992) ’Directive Principles of
State Policy and Fundamental Rights: The
Indian Experience’, South African Journal
on Human Rights 29 (1992)Duggal, Ravi, Nandraj S, Vadair A (1995):
Health Expenditure Across States, Economic
and Political Weekly, April 15 and April 22,
16
Healthcare Case Law in India
7^
Ravi Duggal
I
1
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I
Building on the Synergy between Health
and Human Rights: A Global Perspective
Daniel Tarantola, M.D.
DaM raraMla Senior Poliy Admor to the Director Genern! of the World Health O^atd^ation and an Associate of the
Francois-Xanter Bagnoud CenterJor Health and Ht/wan Rights. Please address correspondence to the author at: Room 7061,
IVrectorGenem/s O/fire. World Ilenllb OiSini~,ilion. Amine Appia. 1211 Geneva 27. Switzerland, or at tarantolad®
mho. ch.
‘
1. Introduction
Bcioie human rights, there was altruism and after human rights there is altruism—the unselfish
concern for the welfare of others. Altruism has been and remains an integral part of the beliefs,
behaviors and practices of public health practitioners. But altruism means different things to different
people. What human rights does for public health is to provide an internationally agreed upon
framework for setting out the responsibilities of governments under human rights law as these relate
to people’s health and welfare.
Human rights as they connect to health should be understood, in the first instance, with
reference to the description of health set forth in the preamble of the WHO Constitution, and
repeated in mam' subsequent documents and currently adopted by the 191 WHO Member States:
1 lealth is a “state of complete physical, mental, and social well-being, and not merely the absence of
disease or inhi'mitv.”1
This definition has important conceptual and practical implications, as it illustrates the
indivisibility and interdependence of rights as they relate to health. Rights relating to autonomy,
information, education, food and nutrition, association, equality, participation and non-discrimination
are integral and indivisible parts of die achievement of the highest attainable standard of health, just
as the enjoyment of the right to health is inseparable from other rights, whether categorized as civil
and political, economic, social or cultural.2 Thus, die right to die highest attainable standard of health
builds on, but is by no means limited to, Article 12 of the International Covenant on Economic,
Social and Cultural Rights.'1 It transcends virtually every single other right.
This paper highlights die long evolution that has brought health and human rights togedier in
mutually reinforcing ways. It will summarize key dimensions of public health and of human rights
and will suggest a manner in which these dimensions intersect in a framework of analysis and action.
It will address these issues against the background of the progress being made by the World Health
Organization towards defining its roles and functions from a health and human rights perspective.
2. When Health and Rights Had Not Yet Met
I
Until only a few years ago, public health and human rights were often considered as two
distinct, almost antagonistic sets of principles and practices. Public health was understood to
promote the collective physical, mental and social well-being of people—this, even if in order to
1 (.onsriturion of the World I Icalth ()rganization, adopted by the International I Icalth Conference, New York, 19 June-22
I
|uly 1946, and signed on 22 July 1946 by the representatives of 61 States.
? Leary V, “The Kight to I lealth,” Wealth and Hunwn Rights, 1 (1994): 28.
5 Article 12, International ('ovenant on Economic, Social and Cultural Rights, adopted and opened for signature,
ratification and accession by United Nations General Assembly Resolution 2200 A(XXI), 1966. I in tercd into force on 3
January 1976 in accordance with article 27.
Copyright C 2000 Daniel Tarantola.
I he /dems expressed in this document a/v solely the responsibility ofits author. The contents ofthis document do not necessarily
rep/vsenl the uiems ofthe institutions to which the author is affiliated nor ofthe Franyois-Xavier Bagnoud Centerfor Health and
Human Rights.
n
achieve public health goals, individual freedom to choose, to behave or to act had to be sacrificed to
the common good.
This was, and continues to be, exemplified by the principles and practices which have guided
the control of such communicable diseases as tuberculosis, typhoid or sexually transmit ted infections,
where quarantine or other restrictions of rights have too often been unposed on affected individuals
without any valid public health justification.
Public health abuses have also been exemplified by the excessive institutionalization of people
with physical or mental impairments where alternate care and support approaches have not been
considered. And far from uncommon is discrimination in the health care setting on the basis of
health status, gender, race, color, language, religion or social origin, or any other attribute that can
impact the quality of services provided to individuals by or on behalf of die Siaic.
In contrast, human rights law has tended to bring into focus the relationship between the
State—the first-line provider and protector of human rights—and individuals who hold their human
rights simply for being human. Even though people hold these rights throughout their lives, they are
nonetheless often constrained in their ability to fully realize these rights. Those who are most
vulnerable to violations or neglect of then rights are also often those who lack the power to evidence
this impact on their wellbeing, including their state of personal health.
'
From an advocacy perspective, until recently, claims for better fulfillment of civil and political
rights have taken precedence over other rights—social, economic and cultural. Human rights
advocates recognized the negative health impact of infringements on civil and political rights—best
exemplified by torture and other forms of degrading treatment.4 Yet many feared that broadening the
spectrum of rights advocacy to encompass the multifarious dimensions of health and rights
violations might dilute the issues and thereby weaken then- claims. Thus, lor a long time,1 health
ignored rights and rights ignored health.
These two worlds remained apart until the 1980s, when reproductive health issues and, later,
HIV/AIDS brought into light the true nature of the relationship between health and rights. This
relationship was not antagonistic, but it was not neutral; it was, in fact, mutually reinforcing and
synergistic.5
The fields of health and rights are illuminated today by their commonalties, no longer by thendifferences. It is now understood that both represent universal aspirations; both are obligations of
governments towards dieir people; and each supports and requires the fulfillment of the other.
Through dieir practice and research, public health and human rights practitioners have the
responsibility to further establish how and to what extent the promotion and protection of health and
human rights interact. What they do not have to do is to show why both health and human rights arc
good for people. In the relendess quest for a world where the attainment of the highest standard of
physical, mental and social well being necessitates, and reinforces, the dignity, autonomy and progress
of every human being, the broad goals of health and human rights are universal and eternal. They
give us direction for our understanding of humanity, and practical tools for use in our daily work.
3. Four Directions for Public Health Action
In May 2000, the World Health Assembly adopted a WHO Corporate Strategy. This strategy
sets out a useful typology which can be used as the backbone for a WHO health and human rights
strategy. The WHO Corporate Strategy addresses four directions for public health:
4 Article 7, International Covenant on Civil and Political Rights, adopted and opened for signature, ratification and
accession by United Nations General Assembly Resolution 2000 A(XX1), 1966. I•’.ntercd into force on 23 March 1976 in
accordance with article 49.
5 Mann JM, Gostin L, Gruskin S. Brennan '1', Lazzarini Z, l•■incberg 11, “I lealth and I luman Rights,” Heu/th cindHiimiin
Rights 1(1) (1994).
2
18
!
I
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•
•
I
I
i
Reduce disease, disability and death by getting informati<ion about who is healthy and who is
not, and by applying proven methods of prevention, care: and support.
Promote healthy lifestyles where the risks imposed on iindividuals by the environment or by
cultural or social constructs are recognized and acted upon.
•
Build health systems that equitably improve health, respond to people’s expressed needs, and
are financially fair.
•
Promote the recognition of health dimensions of social, economic, environmental and
development policies to ensure that such policies and consequent programs contribute to the
advancement of health.
The primary goal of the Corporate Strategy is to advance global public health through an
enhanced interaction between the Organization and its Member States. It also aims to ensure that the
Hippocratic dictum of “first and foremost, cause no harm” is applicable not only to individual but
also public health practices.
If we consider each of these directions for public health through the lens of human rights, we
discover how die lack of respect for human rights can shape our vulnerability to ill health and how,
on (he flip side, the promotion and protection of human rights can be as powerful as a vaccine. Take
as an example rhe core human right of lion-discrimination and the impact that violation or neglect of
ihis right can have on the above-mentioned directions for public health.
Discrimination can impact directly on the ways that morbidity, mortality and disability the
burden of disease—are both measured and acted upon. In fact, the burden of disease itself
discriminates-, disease, disability and death are not distributed randomly or equally within populations,
nor are their devastating effects within communities. Tuberculosis is exploding in marginalized
communities. The AIDS epidemic is finding new vulnerable populations among the poor and those
with unequal status in society, women in particular. Discrimination compounds the effects of
poverty; it is at the root of disease and of premature death. The burden of disease is dependent on
the unequal capacity of individuals to access information, understand the risks to which they have
been exposed, and acquire the ability and freedom both to reduce these risks and to access
preventive and care services when they are needed.
Ill health finds fertile ground in populations that live in the shadows of our societies and are,
therefore, never counted. Acting positively about health and human rights implies recognizing who,
in society, is at a disproportionate risk of ill health. Counting, and counting well, counting while
protecting peoples dignity and privacy, is the beginning of a successful approach towards better
health and rights.
The year 2000 issue of the \V/orld Health Report applied a new set of indicators to help determine
the profiles of national health systems around the world.6 This report posed that health systems have
three goals: achieving good health; enhancing responsiveness to the expectations of the population;
and assuring fairness of financial contributions. For each of these goals, it proposed a composite
indicator to assess the attainment and performance of each nation’s health system. Two of the three
indicators used in measuring attainment—health status and health system responsiveness—were
subdivided so as to reflect overall national level and the disparity within each country. The notion of
inequality was built intrinsically into the third indicator—fairness in financing. It is hoped that this
new assessment method will stimulate countries to recognize the health differentials that national,
aggre8ate nr.easures can hide. As these indicators are further improved and become more “human
rights sensitive,” they may produce relevant evidence for a health and human rights analysis of health
systems. Such an approach could, for example, seek to link disparities in health and health system
performance between and within each nation with progress being achieved in the realization of
human rights, for example the right to non-discrimination.
6 World I Icalth ()rganizatioii: '17/e World Health Report 2000: Health Systems: Improving Performance (Geneva, Switzerland: WHO,
2000).
3
I
Discrimination also affects lifestyles. The patterns of smoking in the world show the tobacco
industry taking a new focus on those with limited access to information and education and those
whose ability to choose and decide on matters related to their own health arc limited by economic
and social pressure. Around the world, lower income, lower education and lower purchasing power
increasingly translate into higher rates of smoking and a higher probability of dying from it.
Multinational companies marketing tobacco operate in a relative vacuum of international law. New
ways have to be found to hold them accountable and for governments to fulfill the human rights
obligations raised by this new challenge, including the rights of children to be protecred'against the
promotion of harmful substance use.
Discrimination in health systems, including health centers, hospitals or mental institutions,
may further contribute to exacerbating disparities in health. Think of migrant workers receiving poor
or no treatment for fear of having to justify their civil status. Think of those who, for reasons of
marginalization related to sexual identity or to behaviors considered to be “against social or cultural
norms” are denied access to treatment available to other individuals. Think of immunizations or
other essential care or procedures that are withheld from children and adults who are thought to be
already affected by other illnesses considered incurable. Think of people with hemophilia who arc
given unsafe blood products on the premises that this adds only a “marginal” risk to their lives, and
think of people with physical or mental disabilities receiving sub-standard care and unable to
complain because their voices are not heard.
Discrimination in health systems concerns not only diseases that are already stigmatized, such as
AIDS, tuberculosis and cancer, but also others, such as diabetes and cardiovascular diseases, which
could be alleviated if equal treatment within societies and within health care settings became the norm.
Discrimination can also be at the root of unsound human development policies and
programs that may impact directly or indirectly on health. For example, an infrastructure
development project may require the displacement of entire populations and fail to pay sufficient
attention to the new environment to which these populations will have to adjust. In the developing
world, the impact of large-scale development programs at the local level is often considered from the
perspective of the possible further spread of such infectious diseases as malaria and other water-born
diseases. The psychological capacity of displaced communities to relocate and rebuild new lives, or
the long-term physical and social consequences of such displacement, are seldom factored into the
equation.
The impact of discrimination on health, whether perpetrated, condoned or tolerated by the
State, is but one—although perhaps the most visible—representation of the health impact of the
violation or neglect of human rights. But there are many other ways, far more subtle, in which health
and rights interact.
We have known for decades that one of the strongest determinants of child health and survival
is the level of educational attainment of the child’s mother. Yet inequality remains in the ability of
boys and girls to enroll in schools and complete primary education—although most governments in
the world have ratified treaties guaranteeing the right of everyone to education.7 To educate children
works towards better health. To protect their health is essential for them to achieve better education
and prepare them better for their lives. Health and human rights converge in the present as they do
in the future.
Human rights and health act in synergy when dignity and privacy^ are protected and when
people can confide in a health system that listens to them and responds to their needs, without
prejudice or arbitrary judgement. The convergence of health and rights is in sight when health
policies are informed by, and respectful of human rights and dignity. Central to the responsiveness of
. health systems to people s needs is the concept of dignity. Respect for dignity is often challenged by
overburdened health systems where time for treating disease seems to compete with time for treaung
patients. Dignity is a hard-to-define concept. However, as the late Jonathan Mann used to remind us,
7 Article 13, International Covenant on Economic. Social and Cultural Rights.
j
4
\
20
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we may find it difficult to define dignity, but we know immediately what it is once our own dignity
has been offended/
4. Three Sets of Governmental Obligations with Respect to Human
Rights
Along with the entire United Nations system, the World Health Organization is in the process
of integrating human rights into its work. For each of the UN agencies, this means analyzing what
they do and do not do in relation to their human rights obligations to respect, protect and fulfill
human rights in their policies, programs and practices. For WHO, it means defining its global public
health responsibilities and role from a health and human rights perspective and drawing a new action
and research agenda. I he process of integrating health and human rights, currently underway at
WHO, requires the development of a strategy that builds on its existing Corporate Strategy. Its
effectiveness is likely to involve conceptual and procedural changes as well capacity building within
the Organization itself and among its Member States.
The construct of a WHO health and human rights strategy may arise from the recognition of
three sets of human rights obligations, in particular as these apply to States and to the UN system, in
this particular instance with regards to health:'’ "’
•
Governments have the obligation to respect human rights, which requires governments to
refrain from interfering directly or indirectly with the enjoyment of human rights. In practice, no
health practice, policy, program or legal measure should violate human rights. The provision of
health services should be ensured to all population groups on the basis of equality and freedom
from discrimination, paying particular attention to vulnerable and marginalized groups.
•
Governments have the obligation to protect human rights, which requires governments to take
measures that prevent non-state actors from interfering with human rights. In practice,
Governments should acquire an enhanced capacity to analyze health-related actions or inactions
attributable to non-state actors on the national and international levels, and act accordingly. This
relates to such important non-state actors as private health care providers, health insurance
companies and, more generally, the health-related industry.
Governments have the obligation to fulfill human rights, which requires States to adopt
appropriate legislative, administrative, budgetaiy, judicial, promotional and other measures
towards the full realization of human rights. In practice, Governments should be supported in
their efforts to develop and apply these measures and monitor their impact, with an immediate
focus on vulnerable and marginalized groups.
•
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5. Applying the Right to Health
As this work has been progressing, in May 2000, the Committee on Economic, Social and
Cultural Rights adopted a General Comment on Article 12 of the International Covenant on
s “ I he ilclmition of dignity itself is complex and thus far elusive and unsatisfying. While the Universal Declaration of
I luman Rights starts by placing dignity first ... we do nor yet have a vocabulary or taxonomy, let alone an epidemiology of
dignity violations. Yet it seems we all know when our dignity is violated or impugned.” Cited from Jonathan Mann;
“Medicine and Public I lealth. I 'thics and I luman Rights,” in: Mann |M, Gruskin S, Grodin MA anil Annas GJ, eds., Health
and Human VJghts: A'Reader (New York: Routledge, 1999), pp. 439—52.
hade A, “Economic, Social and Cultural Rights as I luman Rights,” in: lude A, Krause (', Rosas A, eds., Economic, Social and
CulturalPJghts: A Textbook (Dordrecht: M. Nijhoff, 1995), pp. 21-40.
111 Toebes B., The Right to I lealth as a I luman Right in International Law, School of I luman Rights Research Series, vol. 1,
INTFRSI-NTIA-IIART, 1999.
5
J4
A
soUd document I
B
8
'
' ''‘g'1CS' a"n"’:lb'C Sli,ndi"xl <lf l,Ci'llh " " " :>
SrnrP5d
,
hat W1U’ ,O7r
con«>bute to the understanding, actions and accountability of
States under international human rights law and their health-related obligations - The General
nment lays out directions for the practical application of Article 12 and a monitoring framework
It may be worth commenting briefly here on three selected aspects of the document that hi'e
mtoestof Tubhc I0",/01
MembX^sa^Sui”'8
Pr0SreSsive ^alization; limitations of rights in rhe
°f b^^
bV
Progressive Realization of the Right to Health
fulfillI'l|aU^UntrleSYre7UrCeJ and °ther constrfllnts can make it impossible for a government to
to “e acfiveiZt ofh y
CO?pIete1', The PMC1Ple of “progressive realization” is fundamental
countties dX?
?g
Cy apP1V
,lealth This ,s crl,‘«1 fo‘' 'esource-poor
possible IUs of eauaiP°eT
'“"m8
’Wman nghtS g°als tO tllC maxmmm extent
possible. It is of equal relevance to wealthier countries in that they are responsible for respecting
enXemg .and■
h“man riShts not onIy w^m their own borders, but also through their
ngagement in international assistance and cooperation.
towardher|DlreCTGeneral..nf WHO’ Gr° HarIem Brunddand. h*s c«ed the need to integrate efforts
foimui ih S°a ’ TrnS: n 7" When 8°vernments are well-intentioned, they may have difficult^
fo filhng their health and human rights obligations.
Governments, the WHO and other
intergovernmental agencies should strive to create the condmons favo'rable io health even m
situations where the base of public finance threatens to coUapse.”1-1
The 1978 Declaration of Alma-Ata caUed on nations ro ensure the availability of dief essentials
primary health care (PHC), including: education concerning health problems and the methods for
I
■
of safe water and" b
8
' prOmOti°n °f food suPPb' and proper nutrition; an adequate supply
of safe water and basic sanitation; maternal and child health care, including family planning
rmmumzation against major infectious diseases; prevention and control of locally endemic diseased
appropriate treatment of common disease and injuries; and provision of essential drugs
lc
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-conomic. Social and (.ulrural Rights; (tcncva Switzerland '’() M iv
responsibility to ensure that prevention and care f-u ilirk^*0? r ‘ V^llab,l,t>' essentl;llly provides that governments have a
services are in place and app™^
infrastructures, skilled human resources, goods and
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for immunization; reproductive health needs- provisionTfV-T'l °i
bcalrh Carc r° includc expanding options
and control of „on.communicablc d.seascs; food safety and^oe'is.o'o’f sekS M suppk±r,n'’n'
6
and financial resources that may not match existing or future needs in any country, the principle of
progressive realization takes into account the inability’ of Governments to meet their obligations
overnight. Yet, it creates an obligation on Governments to show how and to what extent they are
achieving progress towards health goals they have agreed to in international fora such as the World
Health Assembly, and those they have set additionally for themselves.
Human Rights Limitations in the Interest of Public Health
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There are situations where it is considered legitimate to limit rights in order to achieve a broader
public good. As'described in the International Covenant on Civil and Political Rights, the public
good can take precedence to: “secure due recognition and respect for the rights and freedoms of
others; meet the just requirements of morality, public order, and the general welfare; and in times of
emergency, when there are threats to the vital interests of the nation.”17
Public health is a public good that may justify the limitation of certain rights under certain
circumstances. Interference with freedom of movement when instituting quarantine or isolation for a
serious communicable disease—for example, Ebola fever, syphilis, typhoid or untreated
tuberculosis—is an example of a limitation on rights that may be necessary for the public good and
therefore may be considered legitimate under international human rights law. Yet arbitrary restrictive
measures taken by public health authorities that fail to consider other valid alternatives may be found
10 be both abusive of human rights principles and in contradiction with public health “best practice.”
The public health response to the I1IV/A1DS pandemic revealed that the sorts of restrictive
measures traditionally applied to epidemic control are generally ineffective or even counter
productive.
11 the limitation of certain rights in the interest of public health remains an option under both
international human rights law and public health laws, the decision to impose such limitations must
be achieved at’ through a structured process. The limitations under consideration must be in the
interest of a legitiijiate objective of general interest. It must be in accordance with the law and strictly
necessary in a democratic society to achieve the objective. There should be no less intrusive and
restrictive means available to reach the same objective; and it should not be imposed arbitrarily, i.e.,
in an unreasonable or otherwise discriminatory manner.”1
Monitoring Health and Human Rights
Mention has been made earlier of the ongoing development of indicators of health outcome (e.g.
morbidity', mortality, disability rates) and health system performance which, by providing national
and sub-national data, create new opportunities for enhancing governmental ability to assess and
report on progress achieved towards realizing human rights in conformity with international human
rights law.1), Yet indicators of disease burden or of performances of health systems may not translate
fully a Government’s commitment or capacity’ to promote and protect human rights in relation to
health.
Equally relevant to' the monitoring of health and human rights are indicators reflecting
compliance with health and human rights principles of the processes of policy and program
development. For example, through appropriately designed indicators and monitoring systems, the
State should be able to show evidence that efforts towards collecting and analyzing data do not
discriminate against anv population groups. It should be able to show that the process of policy
development, program design and resource allocation was/is inspired by, and respectful of, human
rights principles, including participation, equality and non-discrimination.
1 Article 4, Intcntational Covenant on Civil and Political Rights.
IK The Siracusa principles on the limitation and derogation provisions in the International Covenant on Civil and Political
Rights, Annex to UN Doc. It/('N.4/1985/4 of 28 September 1984.
19 Article 16, International Covenant on Civil and Political Rights.
7
I
International accountability of the United Nations system and of its Member States on both
selected outcome and process indicators would provide a clearer representation of the efforts
developed to progress in health and human rights terms, and within the specific context of available
structures, environmental constraints and resources.-' 1 he dual emphasis on outcome and process
monitoring is particularly relevant here, as a long interval may separate the time when chosen
measures are taken from the time their impacts begin to be felt.
6. The Convergence of Health and Rights: From Concept to Action
By combining the four directions of public health and the three sets ol governmental
obligations with respect to human rights, an analytical and action-oriented framework begins to
emerge.21 (See Table 1.) This framework builds on each of the four dimensions of public health:
disease and impact reduction, promotion of healthy lifestyles, strengthening of health systems and
human development policies informed by health. Intersecting with each of these directions are the
three human rights obligations: to respect human rights (not to violate rights), to protect human
rights (to be attentive to non-state actors) and to fulfill human rights (to take measures 10 promote
human rights and establish redress mechanisms). The issues presented in Table 1 are not meant to be
highly detailed, but simply to serve as examples of the points of convergence between health and
rights this approach brings to light.
Each of the intersections between the four directions of public health and the three dimensions
of human rights obligations are rich in questions and suggestive of specific actions. These actions
include the development of adequate monitoring tools reflecting both health and human rights
concerns; the application of health and human rights principles to policy development and practices;
and the creation of a significant research agenda to advance our collective understanding of the
health and human rights relationship.
The framework can be applied to define the roles and responsibilities of WHO in health and
human rights, as well as the technical support the Organization needs to extend to its Member Stares
to reinforce their capacity to translate their commitments under international human rights law into
effective health policies and actions. Although it is intended primarily to guide the development of a
WHO strategy on health and human rights, a similar analytical framework can be applied to
recognition of the points of convergence between health and rights in specific public health domains
such as the design of an approach to disease control. The analysis can begin by identifying public
health options for effective disease control and, using the three sets of governmental obligations with
respect to human rights, consider which intervention achieves the highest results in both health and
human rights terms.22
People engaged in the promotion or protecuon of human rights may begin their analysis by
examining a specific right and seeking how, and to what extent the violation or the lack of realization
of this right may impact on health.
These analyses will be most effective if done in partnership between public health practitioners
and people with substantive knowledge of human rights. This partnership will foster a clearer
understanding of the synergy between health and human rights and provide additional impetus to
Governments to undertake policies, programs and actions that best serve public health while
contributing to the advancement of human rights.
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20Tarantola D: Presentation on behalf of W1 IO on rhe General (Comment on the Kight to the I lighesr Attainable Standard
of Health, before the Committee on ICconomic, Social and Cultural Rights, United Nations I ligh Commission for I luman
Rights, Palais Wilson, Geneva, Switzerland, 8 May 2000.
‘f
2* Gruskin S, Tarantola D, “1 lealth and I luman Rights,” in: The Oxford Te.\-tbook oj Public Health ((ixford University Press, in
press).
22 Gostin L, Mann J: Toward the Development of a I luman Rights Impact Assessment for the I'ormulation and [ '.valuation
of Public Health Policies. In: Health and Human Rights: A Reader, Mann ), Gruskin S, Grodin M, Annas G cds; Routledge,
(1999), 54-71.
8
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Table 1. A Pathway to Health and Human Rights
Domains of
health
1.
Reduce
morbidity,
disability and
mortality
t
I
Governmental obligations
with respect to human rights
_______Respect
Government not to
violate rights of people
on the basis of their
health status including in
information collection
and analysis, as well as in
the design and provision
of health and other
services.
_______ Protect_______
Government to prevent
non stare actors
(including private health
care structures and
insurance providers)
from violating the rights
of people on the basis of
their health status
including in the provision
of health and other
services.
________ Fulfill
Government to take
administrative, legislative,
judicial and other
measures to promote and
protect the rights of
people regardless of their
health status, including
the generation of data
concerning health
outcomes for use in
guiding health policies
and the provision of
health and other services,
as well as providing legal
means of redress that
people know about and
can access.
I.
i
2.
Promote
healthy
lifestyles
Government not to
violate rights, in
particular those violations
which result in, or
perpetuate, lifestyles
associated with increased
morbidity, mortality,
disability.
Government to prevent
non-state from human
rights violations, in
particular those which
result in, or perpetuate
lifestyles associated with
increased morbidity,
mortality, disability.
Government to take
administrative, legislative,
judicial and other
measures including
sufficient resource
allocation to ensure that
healthy lifestyles are
promoted, and provision
of legal means of redress
as applicable.
3.
Strengthen
health systems
Government not to
violate rights directly in
rhe design,
implementation and
evaluation of national
health systems, including
ensuring that they are
sufficiently accessible,
efficient, affordable and
of good quality for all
members of the
population.
Government to prevent
non-srare actors
(including private health
care structures and
insurance providers)
from violating rights in
the design,
implementation and
evaluation of health
systems and structures,
including ensuring that
they are sufficiently
accessible, efficient,
affordable and of good
quality
Government to take
administrative, legislative,
judicial and other
measures including
sufficient resource
allocation and the
building of safety nets, to
ensure that health
systems are sufficiently
accessible, efficient,
affordable and of good
quality, as well as
providing legal means of
redress that people know
about and can access.
t
Contilined onfollowing page
9
4.
Develop health
sensitive policies
and programs
Government not to
violate the civil, political,
economic, social and
cultural rights of people
directly, recognizing that
neglect or violations of
rights impact directly on
health.
Government to
prevent rights
violations by non-state
actors, recognizing that
neglect or violations of
rights impact directly
on health.
Government to take all
possible administrative,
legislative, judicial and
other measures, including
the promotion of human
development
mechanisms, towards the
promotion and
protection ot human
rights, as well as
providing legal means of
redress that people know
about and can access.
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14
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Health and Human Rights
Sofia Gruskin and Daniel Tarantola
I
1. Introduction
for I SlnCC H1C cre |UOn of the United N!,tions OTer fifty years ago, international responsibility for health and
for human rights has been increasingly acknowledged. Yet the actual linkages be ween health and human
lights had not been recognized even a decade ago. Generally thought to be fundamentaUy n gomsttc Tese
together
6P
bUt diStMCt ■ SePame
2
hel^ ‘°
I
and to "rheTT11; ""l "" P°TtO
HIV/AIDS Pande™c; ‘o women’s health issues, including violenceand
the blatant.violations of human rights which occurred in such places as the Balkans and^he Great
I- kes regton tn Africa as havtng brought attention to the intrinsic connections that exist between healthTd
”:l” "-‘'-'y l ad' "l "'<•« issues helped to illustrate distinct, but linked, pieces of the health and human
tights paradigm. While the relationship between health and human rights Jith respect to these and similar
"Th ‘T
ayS
i!” i'r56,“ltulUvel-v’ tbe development of a “health and human rights" language in
last lev teats has allowed tor the connections between health and human rights to beLpltcitlv named
and therefore for conceptual, analytical, policy and programmatic work to begin to bridge these disparate
disciplines and to move fonvard. In the last few years human rights have increasingly been at the center of
analysis and action in regard to health and development issues. The level of institutional and stated political
ll'Zd Nau r<>
'r
'l
man nglltS haS’
faCt’ nCV£r bCen higher' ™S is tme WIthin the work of the
L lined Nauons system but, even more importantly, can also be seen in the work of governments and nongo\ ernmental organizations (NGOs) at both the national and international level.
A. From HIV/AIDS and Human Rights to Health and Human Rights
The
of the
the HIV/AIDS
HIV/AIDS pandemic
pandemic as a catalyst for beginning to define some of the structural
1 ne importance
importance ot
ts cannot
explicitly named in a public health strategy was
response l<> AIDS (WHO 1987) This approach was motivated by moral outrage but also, even tore
mportann b)\ the recognition that protecting the human rights of people living with HIV/AIDS was’a
necessary element of the worldwide public health response to the emerging epidemics. The implications of
his ca 1 were ^-reaching. Framing this public health strategy in human rights terms-although initially
focused on the rights of people living with HIV/AIDS rather than on die broad array of human rights
in uencing peoples vulnerability to the epidemic—allowed it 10 become anchored in international law
lheielty making governments and intergovernmental organizations publicly accountable for their actions
toward peop e living with HIV/AIDS. The groundbreaking contribution of this era lies in the recognition of
t ie applicability of international law to HIV/AIDS issues and in the attention this approach then generated to
the linkages between odier health issues and human nghts-and therefore to die ultimate responsibility and
1994)'ntabl ltV °f the State Under lnternatIonal law for lssues relating to health and well-being (Mann et al.
I
This paper will appear as a chapter in Detels, McEwan, Beaglehole, and Tanaka (eds)
The Oxfon! Texi&»k ofPnh/ir Yhea/th, 4th edition (Oxford University Press, forthcoming).
1 he m ex/mseel /// l/m doewmn! m solely lhe mpomibihly ofits authors. The eoulenls ofthis document do not necessarih represent the
oj the utsttMtons to M the authors are affiliated nor ofthe Franfoit-Xattier Bagnottd Centerfor Health and Human Rtffils.
I
B. International Conferences and the United Nations System
The series of international conferences held in the past decade under the auspices of the I nitcd Nations
system have also been of critical importance in helping to clarify the linkages between health and human
rights. While all of these conferences, ranging from the World Summit for Children, held in 1990, to the
World Conference on Racism, to be held in 2001, are relevant to health and human rights concerns, the two
most crucial in articulating the health and human rights linkage were rhe 1994 International Conference on
Population and Development and the 1995 Fourth World Conference on Women. These conferences
brought together policy makers, activists and representatives from local, national and international agencies,
as well as government representatives. The negotiated documents resulted in the first concrete linkages of
health and human rights in international consensus documents and helped to draw focused attention to the
dual obligations of governments regarding both health and human rights.1 These documents were of use to
governments and others in shaping policy and programmatic work which explicitly dealt with these linkages,
as well as to activists and NGOs in framing their advocacy for government responsibility for health in the
human rights language of responsibility and accountability.
In recent years there has been a substantial increase in attention and resources devoted to
implementation of health and human rights within virtually all UN-development agencies and programs, due
in large part to these international conference processes. All of the organizations and agencies of the United
Nations have, albeit to varying degrees, begun to consider the relevance of human rights to their work in the
health field (Alston 1997). The 1997 Program for Reform put out by UN Secretary-General Kofi Annan,
however, has been most crucial in moving the UN system’s conceptual attention to human rights towards
implementation and action within their own work. The Program for Reform designates human rights as
among the core activities of the United Nations system (UN 1997). The document states that human rights
are to be understood to cut across the four substantive fields of the United Nations’ work: peace and security,
economic and social affairs, development cooperation and humanitarian affairs. Each of the agencies with
responsibility for health currently has policy documents at various stages of elaboration which concern health
and human rights, and technical staff responsible for the integration or implementation of human rights into
at least some aspects of their work, a situation that would have been unimaginable even a few years ago. For
example, the United Nations Children’s Fund (UNICEF) has restructured its policy and programmatic
framework around the Convention on the Rights of the Child (UNICEF 2000); the Joint United Nations
Programme on HIV/AIDS (UNAIDS) recognizes human rights as a cross-cutting theme relevant to all
aspects of its policy and program work;2 a Memorandum of Understanding now exists between the United
Nations Development Program (UNDP) and the Office of the High Commissioner for Human Rights
(UNDP 1999); the UNDP Human Development Report for the year 2000 has an explicit focus on human
rights, and the World Health Organization (WHO) is currently preparing its first-ever strategy on health and
human rights(WHO 1999b). Likewise, the bodies of the United Nations system with responsibility for human
rights are also paying increasing attention to health-related concerns. This is most easily seen in the recent
attention to HIV/AIDS and reproductive health by the human rights treaty monitoring bodies (UNHCHR
1996-98). However, this commitment extends to the recent appointment of two health-related local points in
the Office of the High Commissioner for Human Rights: one responsible for integrating HIV/AIDS issues
into the work of the human rights bodies and structures, and the other serving as a general liaison for all
health and human rights issues.
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1 See, in particular, Chapters IV through VII of the Report of the International Conference on Population and
Development, and chapter IV (C) Women and Health, and (I) Human Rights of Women of rhe Fourth World
Conference on Women.
‘j
2 See UNAIDS Strategic Plan 1996-2000 (Revised December 1995), pp. 5, 6, and 13 where the importance of contextual
factors that increase vulnerability to HIV/AIDS is recognized, including existing discrimination against certain groups!
and where human rights are cited as core values and guiding principles for UNAIDS’ mission.
2
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C. State and Non-State Actors Entering the World of Health and Human Rights
1
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Governments too are increasingly recognizing the relevance of human rights to their health and
development work and calling for technical assistance in the field of human rights. This is true in developing
and industrialized countries alike. In Nepal, a comprehensive workshop was recently held on tuberculosis and
human rights (WHO 1999c). An open debate in South Africa recently focused on the human rights
implications of a proposed new regulation concerning AIDS reporting and AIDS-status disclosure to third
persons. (South Africa Government Gazette 1999) In Colombia, the Convention on the Elimination of All
borms of Discrimination Against Women is being used as a framework for mobilization around much of the
work in family planning (Corporacion Casa de la Mujer 1998; Plata, Yanuzova 1993). Within the United
States, President Clinton issued an Executive Order in commemoration of Human Rights Day in 1998 that
obliges the United States to fully respect and implement its obligations under the international human rights
treaties to which it is a part}’ and to promote respect for international human rights in our relationships with
all other countries (Clinton 1998).” As a result, all U.S. federal agencies, including those with health related
responsibilities, have been directed to re-examine their policies and strategies from the perspective of
international human rights standards.
Non-governmental organizations (NGOs), such as Amnesty International and Human Rights Watch,
are also increasingly considering the implications of the health and human rights connection for their own
work. NGOs that focus on health or development issues, many of which previously saw human rights as
having little relevance to their work, are increasingly using not only the rhetoric of human rights but its
method ol anahsis to help shape their interventions. One prime example is the recent decision of the
International Council of AIDS Service Organizations (ICASO) to name the promotion of human rights in
rhe context of HIV/AIDS as one of its fundamental organizing principles (ICASO 1998). In addition, human
tights NGOs arc expanding their formerly tight focus on civil and political rights to pay increasing attention
to economic, social and cultural rights, including the right to health. These developments are helping to shape
new forms of advocacy and to put increased pressure on governments to take responsibility for the health of
their populatioijs. The current challenge is to ensure that the increased rhetorical attention to rights translates
into policies, national legislation and actions that will effectively impact on the underlying conditions
necessary for health, as well as the ways in which health policies, programs and services are conceptualized
and delivered.
Academics and researchers are also increasingly finding the linkages between health and human rights to
be of critical importance in expanding their domains of work (Alfredsson, Tomasevski 1998; Toebes 1999).
Academic centers with an explicit focus on the linkages between health and human rights are beginning to
appear in a number of places, some with a focus on specific, substantive issues, others concerned with health
and human rights more broadly.5 In the last several years, institutions around the globe have begun to offer
courses in health and human rights, international conferences on health and human rights have been held in a
number of locations, and professional health journals such as The l^ancet, The journal of the American Medical
• Association and the American journal of Public Health have devoted space within their pages to exploring health
and human rights issues (Sonis et al. 1996; Brenner 1996; Leaning 1997;).4
Understanding the implications of linking health and human rights is of increasing importance to policy
makers, government officials, and activists—indeed, to anyone concerned with health issues, human rights
issues or the linkages between the two (Marks 1997). This chapter is intended to demonstrate the basic
relationship between health and human rights, and to provide a glimpse of some of the conceptual, analytical
and practical approaches to bringing health and human rights together that are currently being explored. It
5 See, for example, the Francois-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public
Health, as well as Macfarlane Burnett Center for Medical Research in Australia, the Program on Gender, Sexuality,
Health and Human Rights at the iMailman School of Public Health at Columbia University, Netherlands Institute of
Human Rights (SIM), and the Department of Community Health at the University of Cape Town, South Africa.
4 The first course on health an human rights was offered ar rhe Harvard School of Public Health in 1992. Since that
rime, courses on health and human rights have been increasingly offered in countries ranging from the United States to
France, Sweden, Brazil, South Africa and Zimbabwe. Efforts are currently under way to document existing courses on
health and human rights. Results will be-available from http://www.hsph.harvard.edu/l^bcentcr.
3
I
begins by explaining the basic concepts and procedures of human rights, with specific emphasis on their
relation to health. It goes on to explore the framework of health as it relates to human rights promotion and
protection. The next section considers the reciprocal relationships between health and human rights, with an
emphasis on the human rights impact of public health policies and programs and the impact of neglect or
violation of human rights on health. Attention is then given to suggested methods for increasing the synergy
between health and human rights, both as a method of analysis and as an approach to the design,
implementation and evaluation of health policies and programs. It is hoped that this last section will offer a
method useful for considering the practical application of health and human rights concepts to policy and
programmatic work.
I
2. What are Human Rights?
While human rights thinking and practice has a long history, the importance of human rights for
governmental action and accountability was first widely recognized only after World War II. Agreement ,
between nation-states that all people "are born free and equal in dignity and rights" was reached in 1945 when
the promotion of human rights was identified as a principal purpose of the newly created United Nations
(UN 1945). The United Nations Charter established general obligations that apply to all its member stares,
including respect for human rights and dignity. Then, in 194(8, the Universal Declaration of Human Rights
was adopted as a common standard of achievement for all peoples and all nations (UN 1948). The basic
characteristics of human rights are that they are the rights of individuals, which inhere in individuals because
they are human; that they apply to people everywhere in the world; and that they are principally concerned
with the relationship between the individual and the state. In practical terms, international human rights law is
about defining what governments can do to us, cannot do to us, and should (So for us. For example, governments
obviously should not do tilings like torture people, imprison them arbitrarily or invade their privacy.
Governments should ensure that all people in a society have shelter, food, medical care and basjc education.
The Universal Declaration of Human Rights (UDHR) can well be understood to be the cornerstone of
the modern human rights movement. The preamble to the UDHR proposes that human rights and dignity
are self-evident, the "highest aspiration of the common people," and the "foundation of freedom, justice and
peace." "Social progress and better standards of life" including the "prevention of barbarous acts which have
outraged the conscience of mankind," and, broadly speaking, individual and collective well-being, are
understood to depend upon the "promotion of universal respect for and observance of humah rights" (UN
1948). Although the UDHR is not a legally binding document, nations have endowed it with a tremendous
legitimacy through their actions, including invoking it legally and politically at the national and international
levels. Portions of the UDHR are cited in the majority of national constitutions drafted since it came into
being, and governments often cite to the UDHR in their negotiations with other governments, as well as in
their accusations against each other of violating human rights?
Under the auspices of the United Nations, more that twenty multilateral human rights treaties have been
formulated since the adoption of the UDHR. These treaties create legally binding obligations on the nations
that have ratified them, thereby giving them the status and power of international law. Countries that become
party to international human rights treaties accept certain procedures and responsibilities, including periodic
submission of reports on their •compliance with the substantive provisions of the texts to international
monitoring bodies. The key international human rights treaties, the International Covenant on Economic,
Social and Cultural Rights (ICESCR, 1976) and the International Covenant on Civil and Political Rights
(ICCPR, 1976), further elaborate the content of the rights set out in the UDHR and contain legally binding
obligations for the governments that ratify them. As of January 2000, 142 countries had ratified the ICESCR
and 144 had ratified the ICCPR. Together with the UDHR and the United Nations Charter, these documents
are often called the "International Bill of Human Rights (Humphrey 1976)." Building upon these core
documents, other international human rights treaties have focused on either specific populations, e.g., the
International Convention on the Elimination of All Forms of Racial Discrimination (1965), the Convention
5 A useful compilation can be found in Hannum, H. (1998). The UDI IR in national and international law. / lea/th and
■ Human Rights, 3 (2), 145-58.
4
30
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on the Elimination of All Forms of Discrimination Against Women (1979), and the Convention on the
Rights of the Child (1989), or on specific issues, e.g., the Convention Against Torture and other Cruel,
Inhuman or Degrading Treatment or Punishment (1985).
There are also regional human rights treaties, which essentially concern the same sets of rights but are
only open for signature by states in the relevant region, such as the African Charter on Human Peoples’
Rights (1986), the American Convention on I luman Rights (1992), and the European Convention on the
Protection of Human Rights (1959). Only the Asian region docs noi contain such a treaty. Additionally, there
are numerous international declarations, resolutions and recommendations which, although not strictly
binding in a legal sense, express the political commitment of governments to promote and protect human
rights and provide broadly recognized norms and standards relevant to the topic at hand, e.g., the Declaration
on the Elimination of All Forms of Intolerance and of Discrimination Based on Religion or Belief (1981).
In the past decade, the series of international conferences held under the auspices of the United Nations
have, to a great degree, helped give recognizable content to many of the rights contained in the various
human rights treaties. Out of each of these conference processes has come a Declaration and Program of
Action reflecting the consensus of the nations of the world. Though technically "non-binding" commitments,
these documents demonstrate that there is a consensus of the world community that international human
rights treaty norms encompass the relationship between health and human rights, including reproductive
rights, and that there are steps that ought to be taken at the local, national and international levels to advance
these concerns.
While these conference declarations and programs of action represent nothing more than the political
commitments of the governments present at their inception, the fact that they are then adopted at the next
session of the UN General Assembly gives them a degree of formal standing. Although the Declarations and
Programs of Action from the 1994 International Conference on Population and Development (ICPD
1994)and the 1995 Fourth World Conference on Women (FWCW 1995)have been of particular relevance,
the 1993 World Conference on Human Rights (UN 1993b)and the 1995 World Summit for Social
Developmeijit (UNWSSD 1995) have also helped explicate the relevance of the health and human rights
framework to government action. Individually and collectively, these documents have been of critical
importance in helping to elaborate provisions relevant to vulnerable groups, to women's human rights, and to
broader concepts of health and human rights. Those commitments have helped create new approaches for
considering the extent of government accountability for health issues, as well as for determining the content
of health issues .using a rights framework. In so doing, these conference documents are helping to clarify the
evolving meanijng of the relationship between health and human rights and the steps needed for
implementation’(Gruskin 1998).
3. A Human Rights Perspective on Health
I
The specific rights that form the corpus of human rights law are found in the international human rights
documents. While it is possible to identify different categories of rights, it is also critical to rights discourse
and action to recognize that all rights are interdependent and interrelated, and that individuals rarely suffer
neglect or violation of a particular right in isolation. For historical reasons, the rights described in the human
rights documents have been divided into civil and political rights on the one hand and economic, social and
cultural rights on the other. Civil and political rights include, among others, the rights to liberty, to security of
person, to freedom of movement, to vote, and not to be subjected to cruel, inhuman or degrading treatment
or punishment or to arbitrary arrest or detention. Economic, social and cultural rights include, among others,
the rights to the highest attainable standard of health, to work, to social security, to adequate food, to clothing
and housing, to education, and to enjoy the benefits of scientific progress and its applications. Although die
UDHR contains both categories of rights, these rights were artificially split into two treades due to Cold War
politics, with the United States championing civil and political rights, and the former Soviet Union diose
rights considered to be more economic, social and cultural in nature (Steiner, Alston 1996). Since the end of
the Cold War, acknowledgment of the indivisibility and interdependence of rights has, once again, become
commonplace (UN 1993b). The Convention on the Rights of the Child, the first human rights treaty to be
5
11
opened for signature after the end of the Cold War, is the only one so far to include civil, political and
economic and social rights considerations not only within the same treaty but within the same right.6
Health and government responsibility for health is codified in these documents in several ways. The
right to the highest attainable standard of health appears in one form or another in most every one of them.
Even more importantly, nearly every article of every document can be understood to have clear implications
for health (Mann et al. 1994). While the rights to information, to education, housing and safe working
conditions, and to social security, for example, are particularly relevant to the health and human rights
relationship, specific reference must be made to three rights: the right to nondiscrimination, the right to (he
benefits of scientific progress, and, of course, the right to health.
A. Nondiscrimination
The
ihe principle of nondiscrimination is key to human rights thinking and practice. Under international
human rights law, all people should be treated equally and given equal opportunity Within the international
human rights framework, discrimination is a breach of a government's human rights obligations (Bilder 1992).
Adverse discrimination occurs when a distinction is made against a person that results in their being treated
unfairly or unjustly. In general, groups that are discriminated against tend to be those that do not share the
characteristics of the dominant groups within a society. 1 bus, discrimination frequently reinforces social
inequalities and denies equal opportunities. Common forms of discrimination include racism, gender-based
discrimination and homophobia. Each of the major human rights treaties specifically details the principle of
nondiscrimination with respect to race, color, sex, language, religion, political or other opinion, national or
social origin, property, birth and, as it is called, "other status." 7 (Governmental responsibility for this right
includes ensuring equal protection under the law, as well as in relation to such issues as housing, employment
and medical care. The prohibition of discrimination docs noi mean (hat differences should not be
acknowledged, only that different treatment must be based on objective and reasonable criteria. Although rhe
international human rights documents do not explicidy prohibit discrimination on the basis of health status,
the United Nations Commission on Human Rights has stated that "all are equal” before the law and entitled to
equal protection of the law from all discrimination and from all incitement to discrimination relating to their
state of health" (UN 1992).
I
B. Right to Enjoy the Benefits of Scientific Progress
Closely allied to many of the issues relevant to health is the right to "enjoy rhe benefits of scientific
progress and its applications," recognized explicitly in the ICESCR at Article 15. This right includes
governmental obligations for the steps necessary to conserve, develop and diffuse science' and scientific
research, as well as freedom of scientific inquiry. The implications of this right for health issues have been
explored recently with respect to access to drugs for the developing world, to name one important example
(Lallemant et al. 1994; Reich 2000). In fact, this right is increasingly being cited by activist groups, NGOs and
others concerned by the large and growing disparities and inequities between wealthier and poorer
populations regarding access to anti-retroviral therapies and.other forms of HIV/AIDS’care. In addition, the ‘
relevance of this right to concerns about the development of vaccines that adequately respond to the specific
needs of all populations, both in the north and in the south, has recently been cited (Beloqui et al. 1998; Fluss,
Sec m particular Article 6, which in guaranteeing the right to life includes both rhe more civil and political provision
which states that “every child has the inherent right to life” and rhe more economic and social provision in which “Stare
1 arues shall ensure to the maximum extent possible rhe survival and development of rhe child,” Convention on rhe
ghts of the Child (CRC), G.A. Res. 44/25, UN GAOR, 44th Scss., Supp. No. 49, ar 166, UN Doc. A/44/25 (1989).
See for example, Article 2 of the Universal Declaration of Human Rights, which states in pertinent part, “Everyone is
enutled to all the rights and freedoms set forth in this Declaration without distinction of any kind, such as race, colour,
sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”
6
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I
Little 1999).8 Unfortunately, while this right has long been recognized as relevant to governmental obligations
under the ICESR its implications for health and health-related issues are only just beginning to be recognized.
C. The Right to Health
I
1 he human right to health should be understood, in the first instance, with reference to the description
of health set forth in the preamble of the WHO Constitution and repeated in many subsequent documents.
Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or
infirmity” (WHO 1946). This definition has important conceptual and practical impheations, and it illustrates
the indivisibility and interdependence of rights as they relate to health (Leary 1994; Tomasevski 1995a;
foebes 1999; Kirby 1999). Rights relating to discrimination, autonomy, information, education and
participation are an integral and indivisible part of die achievement of the highest attainable standard of
health, just as the enjoyment of health is inseparable from that of other rights, whether categorized as civil
and political, economic, social or cultural. While the right to health has been set out in a number of
international legal instruments, government obligations under this right are in fact, quite narrowly defined. As
first clabora’ted in the ICESCR, the right is set lorth only as “the right to the highest attainable standard of
physical and mental health, with obligations understood to encompass both the underlying preconditions
necessary for health and the provision of medical care.
It is worth noting here that the apparent tension between the broad definition of health proposed by
W HO, which includes the notion of social well-being, and the more restrictive definition set out in the
ICESCR reflects the very different purposes oi these two documents. The \XrHO definition projects a vision
of rhe ideal state of health as an eternal and universal goal to constantly strive towards, and has as its main
purpose defining directions for the work of the Organization and its member states. The ICESCR definition
differentiates the two attributes of health—physical and mental well-being—and is specifically concerned
with assigning particular responsibilities to the governmental health sector; it assigns obligations relevant to
social well-being to the same governments under other articles of the treaty. The right to health as stated in
the ICESCR, reproduced below, is the principal framework for understanding governmental obligations
under the right to health:
Article 12 of the International Covenant
on Economic, Social and cultural rights
1.
2
The Slates Parties to the present Covenant recognise the right of everyone to the enjoyment of the highest
attainable standard ofphysical and mental health.
7 he steps to be take by the States Parties to the present Covenant to achieve thefull realisation ofthis right shall include
those necessary for:
a., The provision for the reduction of the stillbirth-rate and ofinfant mortality andfor the healthy
development of the child;
b.! 1 .he improvement of all aspects oj environmental and industrial hygiene;
c.
The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
d.
The creation of conditions mhich would assure to al! medical service and medical attention in the event
. of sickness (ICESCR 1976).
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8 See, for example, Statement from rhe community AIDS movement in Africa, presented at the meeting on the
international partnership against HIV/AIDS in Africa, New York, UN Headquarters, December 6-7,1999.
7
X3
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4. Governmental Obligations for Health under International Human Rights
Law
Governments are responsible not only for not directly violating rights, but also for ensuring the
conditions which enable individuals to realize then- rights as fully as possible. This is understood as an
obligation to respect, protect and fulfill rights, and governments are legally responsible for complying with
this range of obligations for every right in ever}' human rights document they have ratified, (Fide 1995a, b;
Maastricht 1997).
f
i
A. Respecting, Protecting and Fulfilling Human Rights
Governmental obligations towards ensuring that every individual enjovs the right to health are
summarized below as an illustration of the range of issues relevant to respecting, protecting and. fulfilling all
human rights:
‘
•
Respecting the right means a state can not violate the right directly. A government violates its
responsibility to respect the right to health when it is immediately responsible for providing medical care
to certain populations, such as prisoners or the military, and it arbitrarily decides to withhold that care.
•
Protecting the right means a state has to prevent violations of rights bv non-state actors and offer some
sort of redress that people know about and can access, if a violation docs occur. This means the state
would be responsible for making it illegal to automatically deny insurance or health care to people on rhe
basis of a health condition, and they would be responsible lor making sure some system of redress exists
that people know about and can access if a violation does occur.
•
Fulfilling the right means a state has to take all appropriate measures—including but not limited to
legislative, administrative, budgetar}' and judicial—towards fulfillment of the right, including the
obligation to promote the right in question. A state could be found to be in violation of the right to
health if it failed to incrementally allocate sufficient resources to meet the public health needs of the
communities within its borders.
In all countries, resource and other constraints can make it impossible for a government to fulfill all
rights immediately and completely. The human rights machinery recognizes this and acknowledges dial, in
practical terms, a commitment to the right to health is going to require more than just passing a law. It will
require financial resources, trained personnel, facilities and, more than any tiling else, a sustainable
infrastructure. Therefore, realization of rights is generally understood to be a matter of progressive realization
of making steady progress towards a goal (ICESCR, Art. 2.1; Alston, Quinn 1987). The principle of
progressive realization" is fundamental to the achievement of human righis. This is critical for resource poor
countries that are responsible tor striving towards human rights goals to the maximum extent possible. It is
also of relevance to wealthier countries in that they are responsible, for respecting, protecting and fulfilling
human rights not only within their: own borders, but through their engagement in international assistance and
cooperation (UN 1984).
B. Valid Limitations on Human Rights
In spite of the importance attached to human rights, there are situations where it is considered legitimate
to restrict rights in order to achieve a broader public good. As described in the International Covenant on
Civil and Political Rights, the public good can take precedence to: “secure due recognition and respect for the
rights and freedoms of others; meet the just requirements of morality, public order, and the general welfare;
and in times of emergency, when there are threats to the vital interests of the nation” (1CCPR Art. 4). Public
8
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or poL head,
p.bi.c
.b“”
n„k
1 roudcs examples of this type of abiise(R. Cohen,Wiseberg 1990, LN 1992a; UN 1994, HRI 19981
Certain rights are absolute, which means that restrictions mav never be placed on’them evenif justified
forbidden is
necessary under narrowly defined
circumstances in many situations relevant to public health." Limitations
on rights, however, are considered a
serious issue under international human rights law, regardless of the ;
apparent importance of the public good
involved. W hen a government limits the exercise or enjoyment of a tight, tins
> action must be taken only as a
Iasi resort and will only be considered legitimate if the following criteria
are met:
1.,
3.
4.
restrlctlon « provided lor and carried out in accordance with the law;
he restriction is in the interest of a legitimate objective of general interest;
I he restriction is strictly necessary in a democratic society to achieve the objective'
here are no less intrusive and restrictive means available to reach die same goal' and
Jnlcosoc
1 '■ ....... ...........
W hereas tins approach, often called the S.racusa Pnnctples, because they were conceptualized at a
meeting in Siracusa, Italy, has long been recognized by those concerned with human rights monitoring and
nplementation as relevant to analyzing a government’s actions, it has also recently begun to be considered a
JcoX^Vo/UN AmS
S
rCSp"nS1“e Wlthln ^ernment for heakh-related policies and
nulX h (7I1^/UNAIDS 1’")- Thl!j framework, although still rudimentary, may be helpful in identifying
public health actions that are abusive, whether intentionally or unintentionally.
g
5. Human Rights Monitoring Mechanisms Relevant to Health
The degree of governmental compliance with
with the
the obligations
obligations to respect, protect and fulfill human rights
■ le of direct relevance to die people affected, but they are also of interest to die international community.
Zu r'u) mT'icrtcr' I
nRht in "1C Srate °f PUMC hC:,lrl1 C>'n be underst°°d
I
1
9
I
be derived from
- (cj.of tlK
R, Which gives governnu nls the right to take the steps they deem necessary for the
preiention, treatment and control of epidemic, endemic, occupational and other diseases.”
,h'ire“N.fOrdCX;!mP'C' AfrtlCle 4 °?he I"rernational Covenant on Civil and Political Rights, which states in pertinent part
that No derogation from articles 6, 7, 8 (paragraphs 1 and 2), 11, 15, 16, 18 may be made under this provision P
See for example. Article 4 of the ICCPR, which states in pertinent part, "In time of public emergency which threatens
he life of the nation and the existence of which is oflicially proclaimed, the States Parties to the present Covenant may
e measures derogating from their obligations under the present Covenant to the extent strictly required by the
7
exigencies o the Mtuation, provided that such measures are not inconsistent with their other obligations under
in^national law ;jnd do not involve d.scnmmation solelv on the ground of race, colour, sex, lan^age, religion or social
■
The accountability of governments for their legal commitments is monitored at the international level
through the reporting process and, in many places, at the national level by governments themselves thiough
the creation of commissions and ombudspersons, as well as b\ NGOs.
A. Reporting under the Human Rights Treaties
to report
As mentioned previously, once a government has ratilled a human rights treaty’, it is obliged
Jl r t-1 ■>n f t ri•n It
every several years to the specific body responsible for monitoring government action under that treaty.
Governments are responsible for showing the ways diey arc and are not in compliance with the treaty
provisions, and must show constant improvement in their cl torts to respect, protect and fulfill the rights in
question (UN 1996). Each of the treaty bodies meets several times each year to review a number oi the
government reports submitted. The process is very formal, with the government under review submitting a
copy of their report approximately two months before the meeting. The report is officially presented at the
meeting by a high-ranking government official, and the treaty body engages in formal dialogue with the
country in question. Health-oriented UN institutions, such as WHO, UNAIDS or UNICEF, ar? invited to
provide the treaty bodies with information on the state of health and the performance of health systems in
the country under review. NGOs can also submit informal reports (often termed shadow reports) providing
additional information, as well as stating their views on the situations and issues at stake. At the conclusion ol
the session, the treaty body prepares Concluding Comments and Observations, which are made part of the
substantive record. These comments address the extent to which the government in question is in compliance
with its treaty provisions and provide concrete suggestions for actions to be taken by the country in order for
it to be found in compliance at its next review. While ibis process can be extremely useful, there is,
unfortunately, a tremendous backlog, largely because governments are often late in their reports, and none of
the treaty bodies meets for a sufficient amount of time each year to cover all of the countries that are
responsible for reporting to it.
At this point in time, all of the human rights treaty' bodies have expressed a commitment to exploring
the implications of health broadly defined, as well as the specific issues raised by both HIV/AIDS and
reproductive health concerns, for governmental obligations under the treaties (UNDAW, UNFPA,
UNHCHR 1996; Boerefon, Toebes 1998). While several of the treaties contain specific health-related
provisions, the added impetus to pay attention to health in the context of monitoring work can largely be
attributed to the interest generated from international conferences and the political commitments made there
about governmental responsibility' for ensuring the human rights of individuals in relation to health.
For each of the human rights treaties, General Guidelines for Reporting provide guidance to
governments as to how to present the information about then compliance with their obligations to the ireatv
bodies (UN 1996). The information requested by the treaty bodies concerning health-related issues relates to
what governments are doing with respect to both the underlying preconditions for health and the ways in
which health policies, programs and sendees are designed and implemented. From a health perspective,
however, the actual information requested under current requirements is largely insufficient to get at this
range of issues. The General Guidelines provided to governments for reporting on the right to health under
the International Covenant on Economic, Social and Cultural Rights are included below (Box 1). They
provide a concrete example of what the treaty body with primary responsibility for implementation of the
right to health considers in determining if and the degree to which a government is in compliance with its
obligations for the right to health.
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Box 1.
Guidelines for Reporting on Article 12 of the ICESCR
I
/.
I ease
injormation on the physical and mental health ofyourpopulation, both in the a^repate and with respect to
digerent groups withinyour society. How has the health situation changed oner time with regard to these groups? In case
yourgom-nwent has recently submitted reports on the health situation inyour country to the World Health OrganHation
(WHO) yon may wish to refer to the relevant parts of these reports rather than repeat the information here.
2
Please indicate whetheryour country has a national health policy. Please indicate whether a commitment to the WHO
primary health rare approach has been adopted as part of the health policy ofyour county. Ifso, what measures have
been Ia ken tn implement primary health care?
Please indicate ivhat percentage of your GNP as mdl as ofjour national and/ or regional budget(s) is spent on health.
What percentage ofthose resources is allocated to primary health care? How does this compare with 5years ago and 10
years ago?
Please provide, where available, indicators as defined by WHO, relating to thefollowing issues:
(a) Infant mortality rate (in addition to the national value, please provide the rate by sex, urban/ rural division,
"'d also, if possible, by socio-economic or ethnic group and geographical area. Please include national definitions
of urban/rural and other subdivisions):
(b) Population access to safe water (please disaggregate urban/ rural);
(c) ' Population access to adequate excrete disposalfacilities (please disaggregate urban/rural);
(d) Infants immunised against diphtheria, pertussis, tetanus, measles, poliomyelitis and tuberculosis (please
disaggregate urban/rural and by sex);
(e) Ufe expectancy (please disaggregate urban / rural, by socio-economic group and by sex);
(!) Proportion ofthe population having access to trained personnelfor the treatment ofcommon diseases and
injuries, with regular supply of 20 essential drugs, within one hour's walk or travel;
(g) Proportion ofpregnant women having access to trained personnel during pregnancy and proportion attended ly
such personnelfor delivery. Please provide figures on the maternity mortality rate, both before and after
childbirth.
(h) Proportion of infants having access to trained personnelfor care.
(Please provide breakdowns by urban/ rural and socio-economic groupsfor indicators (/) to (h)).
Gan it be discernedfrom the breakdown of the indicators employed in paragraph 4, or by other means, that there are any
groups inyour country whose health situation is significantly worse than that of the majorly of the population? Please
define these groups as precisely as possible and give specifics. Which geographical areas inyour country if any, are worse
off with regard to the health of their population?
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(a) During the reporting period, have there been any changes in national policies, laws and practices negatively affecting
the health situation of these groups or areas ? If so, please describe these changes and their impact?
(b) Please indicate what measures are considered necessary byyourgovernment to improve the physical and mental
health situation ofsuch vulnerable and disadvantaged groups in such worse offareas.
(c) Please explain the policy measuresyourgovernment has taken, to the maximum ofavailable resources, to realise
such improvement. Indicate time-related goals and benchmarksfor measuringyour achievement in this regard.
(d) Please describe the effect of these measures on the health of the vulnerable and disadvantagedgroups or worse off
areas underyonsideration. and report on the successes, problems and shortcomings of these measures.
(e) Please describe the measures taken byyourgovernment in order to reduce the stillbirth rate and infant mortality and
to provide for the healthy development of the child.
(/) Please list the measures taken fry yourgovernment to improve all aspects of environmental and industrial hypiene.
..•ir.lll.lli
»»»..»•
11
^7
Please describe the measures taken by your government to prevent, treat and control epidemic, endemic and
occupational and other diseases.
(h) Please describe the measures taken byyour government to < ismiiv to all medical service and medical attention /// the
event of sickness.
(i) Please describe the effect of the measures listed in subparagraphs (e) to (h) on the situation of the vulnerable and
disadvantaged groups inyour society and in any worse-off areas, Report on difficulties andfailures as well as on
positive results.
(g)
I
6.
Please indicate the measures taken byyour government to ensure that the rising costs ofhealth carefor the elderly do not
lead to infringements on these persons’ right to health.
7.
Please indicate what measures have been taken in your country to maximize community participation in the planning,
organisation, operation and control ofprimary health care.
8.
P/easc /mlii'dle what measures bare been lah’n m year countr\ :<> ,hioi'/<ic editcahun concerning prevailing health problems
and the measures oj preventing and controlling them.
Please indicate the role of international assistance in thefull realisation of the right enshrined in \rticle 12.
(UNECOSOC 1991).
'
.
9.
f
’
The increasing linkages among the work of the treat}- bodies, the UN specialized agericies and NG Os
are useful to the treaty monitoring process, but they are also beginning to contribute directly and concretely
to enhancing implementation of human rights at the country level by governments as well as other actors.
The role of the technical and specialized agencies, funds and programs of the UN in the treaty monitoring
process is growing, with respect to both provision of information and interactions with the treaty bodies and
governments in question. This includes primarily UNICEF7, UNAIDS and WHO but also, inci'easingly, the
International Labour Organization (ILO), UNDP and UNFPA. More and more, these agencies and programs
have been providing the treaty bodies with statistical information and other data collected as part of their
routine work concerning the country in question to assist the treaty bodies in their review of government
compliance. I bey have also been providing treaty bodies with guidelines and other examples of "best
practice” they have produced, which can assist the treaty bodies in their analysis of the information provided
by the government and in the drafting of their Concluding Comments and Obsen’ations. To date, however,
the input of these agencies has been somewhat uncoordinated, even within the same institution, often
resulting in heavy servicing ol some treaty bodies in some specific ways while virtually ignoring others. As a
result, a country may be heavily questioned by one treaty body as to some specific aspect of their compliance
with their health-related obligations under one treaty but questioned not at all by another treaty body
responsible for monitoring similar health-related obligations. In addition, due to lack of resources and the
relative newness of their engagement with this process, the UN agencies, funds and programs do not provide
even the treaty bodies they do work with equivalent information on all countries reporting at a particular
time. Thus, while one country may be heavily questioned by a treaty body as a result of information provided
by a particular agency, the next country immediately under review may not even be questioned superficially
on comparable issues. UNICEF has been involved in the treat\ monitoring process in other ways as well. For
example, it has expended considerable resources on helping governments to prepare their reports as well as
increasingly framing technical assistance to countries according to the provisions of the Convention on the
Rights of the Cliild (UNICEF 1998). This approach to the work of UN agencies and programs at the country
level has increasingly been considered of interest by the other technical agencies of the United Nations,
especially UNAIDS and WHO, and may help to frame some ol their work in the future.
Non-governmental organizations play a critical role to play in monitoring governriient compliance with
treaty provisions. In countries, NGOs are increasingly using government obligations under the human rights
treaties, as well as the Concluding Comments and Observations of the treaty bodies, in their advocacy efforts.
The input of NGOs is also crucial at the international level in that they are able to provide treaty monitoring
12
38
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I
bod.es with tnuch-needed addmonal outstde tnformatton on the acuon (or tnaction) of the government tn
question, which> can then be used by the treaty body m their dialogue with that government Akhoueh n2os
are sometimes piesent during the formal dialogue, this information is most often presented in shadow
reports. There ik no formal mechanism, however for ensuring rhnr NCO infA
bodies, and, unfortunately NGOs eenerallv dn
rlu NGi° ^formation gets to the treaty
lack of functioning NGOs i:
Tins la t nCoinr',C "'f
7
^lattonships with the treaty body members than other orgalatiols do
last point is of particular concern in relation to health-related human rights issues, as the! issues often
he ilrl
I r l
PUTW e malnstream human r«hts organizations, and' Lie alternative information on
invo
i f Mr A
7" te
CS the releVi,nt b°dleS (UNAIDS 1997). As a result, while the utility of the
, oh emen of NGOs to this process is at this point undisputed, mechanisms for ensuring their invokement
comprehensive way, particularly with respect to health-related information, still remain to be worked out.
B. General Recommendations and General Comments Concerning Health
to lJwthe P:'S1 11Ve ' e!lrS' there haVe been lncrvas,n8 efforts to dr!lft authoritative interpretations of the right
to health n order to ensure state responsibility and accountability with respect to health in a structured way
I hese authornauve interpretations have taken the form of General Comments or General Recommendations'
treL’Ld driffted 7^ “d°rSed by tbe. Ueaty mo'ut°nng body in question and which form the basis of the
Ge 1 ral RV '
'
the
of a particular right or issue. These General Comments or
Recommendations then help to serve as a guide for governments concerning the issues they must
consider in making their periodic reports under rhe guidelines, for non-governmental organizations in their
monitoring ol governmental acuon and for the treaty bodies themselves in their dialogue and interaction with
go ernments in the context of the monitoring process (UN 1996). While these comments and
recommendations are meant only to provide interpretation, their formulation does have concrete implications
“J1' j 1,el]°r nOtfa go''ernment « Ndged to be m compliance with its treaty obligations. For example, the
light o healtn as formulated in international treaties contains no mention of primary health care In large
i
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t
CJ°nCept °f Prlmary heal11’ care had not y£t been internationally recognized at the time
the ICESCR was drafted. While the guidelines for reporting contain substantive mention of primary health
care, the rt arionship between a primary health care approach and government obligations under the treaty
are not spelled out I hus, tn the absence of a general comment or recommendation emphasizing a pritaary
health care approach, it is difficult to judge a country that pays little or no attention to primary health care not
co be in compliance with its health related obligations.
Until very recently, no general comments or recommendations had been issued by any of the treaty
bodies specificallv related tp health. In 1999, the CEDAW Committee, which monitors governmental
compliance under the Women’s Convention, issued a General Recommendation on Health, and in 2000 the
committee on Economic, Social and Cultural Rights, the body responsible for monitoring the ICESCR
issued a General Comment on the Right to I lealth (CEDAW 1999, CESCR 2000). Nonetheless, a number of
the general comments and recommendations issued by the treaty bodies in past years have had clear healthrelated implications. These include the General Comments on Disability, Housing and Food issued by the
1£ciOnO*nJC’ Social and Cultural
and the General Recommendations concerning
HIV/AIDS, Female Circumcision and Violence against Women issued by the CEDAW Committee
(I NCEDAW 1989; UNCEDAW 1990 a, b; UNCESCR 1994; UNCESCR 1995; UNCESCR 1997).
At the outset of the 21-^ century, the translation of the right to health into guidelines and other tools
useful to national and international monitoring of governmental and inter-governmental obligations is still in
its infancy. 1 he CESCR General Comment on the Right to the Highest Attainable Standard of Health, which
13
3<|
was adopted in 2000, may help to provide some useful
useful guidelines.
guidelines. In
In parallel,
parallel, as described later in (his
chapter, WHO is developing a new set of tools and recommendations aimed at redirecting the attention given
to monitoring global health indicators from disease-specific morbidity and mortality trends towards others
that are more reflective of the degree to winch health and human rights principles are respected, protectee
and fulfilled (WHO 2000b in press). How and to what extent these instruments will actually be put to use and
how effective they will be in advancing the health and human rights agenda has yet to be seen, but there are
several factors that, even at this early stage, allow for guarded optimism, hirst, the treaty bodies and
international organizations concerned with health are doing this work based on open dialogue and a degree ot
collaboration that greatly exceeds the level and quality of inter-agency collaboration traditionally obseiwed
within the UN machinery. This is exemplified by the sharing of g(»als and (he collective icchnical cooperalion
that has prevailed in the current processes of defining obligations and monitoring methods and standaids
relevant to health and human rights in the process of operationalizing both the international treaties and the
recommendations promulgated at the international conferences (UNDAW, UNFPA, UNHCHR 1996;
UNDP 1998b, WHO 2000c). Potentially, this work will help not only to monitor what governments are
doing, but also to build their capacity to incorporate health and human rights principles into their policies and
programs. In several countries, including Brazil, Thailand and South Africa, human rights principles relevant
to health recently have found their way into national legislation and new constitutions, thereby ensuring
citizens the right to seek fulfillment of their right to care, lor example, through national juridical means
(Hannum 1998). As the methods and tools for monitoring and accountability of health related issues mature,
it is likely that cases of human rights violations related to health will increasingly be heard both within
countries and at the regional and international level.1" A focus on monitoring and redress of violations ot the
right to health is but one means of ensuring action using the human rights documents. iLqualujy important are
the steps being taken to build national and international capacity to develop and reform public policy and
laws in line with international human rights norms and standards as they apply to health (UNFPA 1998). 1 his
work requires institutional changes, as well as capacity building within both governmental systems and
international organizations. The Director-General of WHO has cited the need to integrate efforts towards
this goal, noting: "Even when governments are well-intentioned, they may have difficulty fulfilling their health
and human rights obligations. Governments, tire WHO and other intergovernmental agencies'shojuld strive to
create the conditions favorable to health, even in situations where the base of public finance threatens to
collapse" (Brundtland 1998).
The process of "mainstreaming human rights", currently well underway in the UN system, is specifically
aimed toward this goal (UN 1997a). Mainstreaming human rights is "the process of assessing the human
rights implications of any planned action, including legislation, policies or programs,* in all areas and at all
levels. It is a strategy for making human rights an integral dimension of the design, implementation,
monitoring and evaluation of policies and programs in political, economic and social spheres (UN 1997a)."
Two examples may serve to illustrate how this is done. In the 1990s, UNICEF adopted the Convention on
the Rights of the Child (CRC), thereby ensuring that their policy and programmatic work would be guided by
the principles and standards established by the CRC, as well as the Convention on (he Elimination of All
Forms of Discrimination Against Women. The 1996 Mission Statement says explicitly that pursuit of the
rights of children and of women is a fundamental purpose of rhe organization. These efforts have led ro a
restructuring of UNICEF and a nghts-based approach to all programming efforts at all levels of its work
(UNICEF 1998). In WHO, a similar process began in 1999 with (he aim of defining rhe goals of human
rights mainstreaming for their national and international health work (WHO 1999b). The process was begun
following a 1998 World Health Assembly Resolution that set out the need to "promote and support the rights
and principles, actions and responsibilities enunciated in the [World Health Declaration! through concerted
action, full participation and partnership, calling on all peoples and institutions to share the vision of health
for all in the twenty-first century, and to endeavor in common to realize it (WHO 1998c)." In 2000, work
began toward a strategy document which would incorporate health and human rights into the policy and
12 See, for example, Open Door Counselling and Dublin Well Women’s Centre v. Ireland, 15 EUR. H.R. Rep. 244
(1992).
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program work of WHO. Toward this aim, health and human rights are considered relevant to each of WHO’s
four strategic directions (WHO 1999b):
1.
2.
3.
4.
Reducing excess mortality, morbidity and disability, especially in poor and marginalized populations;
Promoting healthy lifestyles and reducing risk factors to human health that arise from environmental,
economic, social and behavioral causes;
Developing health systems that equitably improve health outcomes, respond to people’s legitimate
demands and are financially fair;
Developing an enabling policy and institutional environment in the health sector and promoting an
effective health dimension to social, economic, environmental and development policy (WHO, 1999d).
These strategic directions will be discussed more extensively below with specific reference to their health
and human rights implications. To pursue these directions, WHO is proposing to contribute to the building
of skills and knowledge within the Organization and in countries; perform an internal review of its policies
and programs to verify their conformity with health and human rights principles; further its cooperation with
rhe Office of the High Commissioner for Human Rights and the treaty monitoring bodies; disseminate
information; and develop and refine human rights-sensitive monitoring and evaluation processes applicable
nationally and internationally.
6. A Health Perspective on Human Rights
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As stated above, over fifty years ago, the Constitution of WHO projected a vision of health as a state of
complete physical, mental and social well being—a definition of health that is more relevant today than ever
(WHO 1946). It recognized that the enjoyment of the highest attainable standard of health was one of the
fundamental rights of every human being and that governments have a responsibility for the health of their
peoples, which can be fulfilled only through the provision of adequate health and social measures. The 1978
Declaration of Alma-Ata called on nations to ensure the availability of the essentials of primary health care,
including: education concerning health problems and the methods for preventing and controlling them;
promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning; immunization against major infectious diseases;
prevention and control of locally endemic diseases; appropriate treatment of common disease and injuries;
and provision of essential drugs (WHO/UNICEF 1979). In 1998, the World Health Assembly reaffirmed the
commitment of nations to strive towards these goals in a World Health Declaration that stressed the "will to
promote health bv addressing the basic determinants and prerequisites for health" and the urgent priority “to
pay the greatest attention to those most in need, burdened by ill health, receiving inadequate services for
health or affected by poverty " (WHO 1998). These ambitious objectives of health development must be
examined from the perspective of the role of governments in ensuring equal and equitable access to medical
care and health promotion while striving to create the underlying conditions necessary for health.
This section will begin with a discussion of the traditional dichotomy between the roles and functions of
medicine and those* of public health, which will help begin to frame the content of governmental obligations
towards individuals and populations for health under international human rights law. Health will then be
placed in the broader context of human development in order to underscore the relevance of a broad array of
governmental obligations, well beyond the heal I h sector, that may impact on health. The four strategic
directions to health development mentioned earlier will then be presented as an approach relevant to the
developnhent; of both a health and human rights analysis and monitoring And accountability. Finally, a new
grouping of these issues will be proposed as an entry point into their analysis from a human rights
perspective, leading to a pathway for action.
A. Medicine, Public Health and Human Rights
Health i;is it connects to human rights analysis and implementation concerns two related but different
disciplines: medicine and public health. Historically the territorial boundaries of medicine and public health
15
reflected not only professional interest and skill, but also the environments within which these skills were
practiced' homes, clinics, hospitals and clinical laboratories on rhe one hand; institutes, public heat!
laboratories, offices and field projects on the other (Detels et al. 1997). In recent years,(the apparent
differences between the two professions—the first primarily understood to focus on the health :of individua s,
the second on the health of populations—have profoundly impacted the ways in which the relationship
between health and human rights has been understood by different actors. From a rights perspective, this
ancient division resulted in the assumption that, of the two, medicine was more concerned with the health
and rights of the individual (for' example, in creaung conditions enabling a particular individual to access
care), while the primary focus of public health was the protection of coUective interests, even'at (he cost of
arbitrarily restricting individual rights (Mann 1997). For example, coercion and restrictions of rights had been
critical to traditional smallpox eradication efforts (Fenner et al. 1998). Yet as the human rights approach has
made increasingly clearer, this stark differentiation between medicine and public health is no longer fully
relevant either to human rights or to health. Although they apply different methods of work, both medicine
and public health seek to ensure every person's right to achieve the highest attainable standard of health, and
both have a strong focus on the individual. Medicine is more concerned with analyzing, diagnosing and
treating disease, as well as preventing ill health in individuals through such methods as immunization,
appropriate diet or prophylactic therapies. Public health seeks to address health and ill health by focusing on
individual and coUective determinants, be they behavioral, social, economic or other contextual factors.
Three sets of factors have contributed to blurring traditional boundaries between medicine and public
health in past decades. First, the transitions in health status through which many populations have been
recently evolving have caUed for a closer understanding of the links between individual health, public health
and die environment (Gubler 1998, Shrader-Frechetter 1991). Contemporary thinking about optimal
strategies for disease control have evolved, as efforts to confront the most serious global health threats
including cancer, mental disorders, cardiovascular disease and other chronic diseases, injuries, reproductive
and sexual health, infectious diseases and individual and coUective violence have increasingly emphasized the
role of personal behavior within a broad social context (Murray, Lopez 1996). The transition of the global
disease burden moving from communicable diseases to non-communicable diseases, which are understood to
be heavUy dependent on Ufestyle, has evoked a medical need to care for patients in the context within which
they are born and grow through chddhood and adulthood until death. There has been increasing
understanding that behaviors and their social, economic and cultural contexts are inextricably interwoven
with the biolog}’ of health and disease, and are therefore relevant to individual care (Krieger, Sidney 1996).
Second, the tools and technologies of each field have been found to be of increasing utility to the other.
For example, new technologies developed through biomedical research in such fields as immunolog}’,
molecular biology and genetics are of increasing relevance to public health (Barry, Molyneux 1992; Andrews
1995; Aluwiharc 1998). Scientific discoveries in molecular virology have provided tools that arc as useful to
individual diagnosis and care as they are to epidemiology, vaccine development and pubbe health programs
(Hunter 1999). Likewise, traditional pubhc health tools, drawn from epidemiology, ecology and social and
behavioral sciences, have demonstrated their usefulness in deciphering powerful determinants of health and
of disease outcomes, thus creating stronger bridges between biomedical care and public health interventions
(Krieger, Zierler 1997; Terragni 1993).
Third, the human rights framework has shown that the state’s human rights responsibilities to respect,
protect and fulfill rights relating to health include obligations concerning both medicine and public health. In
the context of a health and human rights analysis, a challenge ro the now-artificial dichotomy between
medicine and public health is not merely rhetorical or of analytical interest; it also brings into play the range
of obligations of the state towards ever}' individual. The health and human rights paradigm is relevant ro
clinical practice, community health, large-scale health program development, implementation and policy. 1 he
synergistic health and human rights perspective aims to guarantee that every individual can achieve the
highest attainable standard of physical, mental and social well being. Human rights are progressively being
understood to offer an approach for considering the broader societal dimensions and contexts of the well
being of individuals and populations, and therefore to be of utility to all those concerned with health.
B. Globalization and Health Development
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The definition of health enshrined in the WHO Constitution was an important step in helping to move
health thinking beyond a limited biomedical- and pathology-based perspective towards the more positive
domain of well being, understood to include recognition of individuals and their need to realize aspirations, to
satisfy needs and to change or cope with then environments. The societal dimensions of this effort were
emphasized in both the Declaration of Alma-Ata (1978), and the Ottawa Charter for Health Promotion
(1986). The Alma-Ata Declaration describes health as a social goal whose realization requires the action of
many social and economic sectors in addition to the health sector. The Ottawa Charter proposes that the
fundamental conditions and resources for health are peace, shelter, education, food, income, a stable
ecosystem, sustainable resources, social justice and equity'.
Wlien WHO was created to improve health 50 years ago, there were hopes that antibiotics and the
progress achieved in vaccines and biomedical technology’ would provide the tools sufficient to enable
individuals everywhere in the world to reach the highest attainable standard of physical, mental and social
well-being (Tomasevski, 1995b). However, decades later, as reflected in both the Alma-Ata Declaration and
the Ottawa Charter, it is now clear that regardless of the effectiveness of technologies, the underlying civil,
cultural, economic, political and social conditions at both a global and local level have to be addressed as well.
The major determinants of better health are increasingly understood to lie outside the health system and to
include better education and information, as well as fulfillment of an array of rights which are relevant to, but
not intrinsically connected to, the right to health (Carrin, Politi 1996). Thus health requires attention to the
increasingly complex relationship of people to their environment and an understanding of respecting,
protecting and fulfilling human rights as a necessary prerequisite for the health of individuals and populations.
Globalization and the direct and indirect impacts of intensifying global flows of money, trade,
information, culture and people on health and related aspects of human development, have brought out a
new set of human rights issues (Brundtland 2000). These issues need particular attention, as they have largely
been ignored up to now. The process of globalization has proceeded at a much faster pace than the
development of policies aimed at maximizing its benefits to human development and preventing or mitigating
its harmful effects.
Globalization, and the privatization of (he means of production and services that inherently
accompanies it, can contribute to the advancement of health through the sharing of information, technologies
and resources, as well as through the compel it ion it generates to provide more effective, more widely'
available and higher-quality' services. Globalization can create new employment opportunities in some
populations or sectors of the economy, but at tunes may do so to the detriment of others. It can also
stimulate the spread of health hazards and disease as a result of intensified population mobility, or through
the worldwide marketing of harmful substances, such as tobacco and alcohol. If poorly conceived and
monitored, globalization can contribute to the widening of inequalities by increasing the autonomy and wellbeing of some sectors of the population while producing negative consequences for others without access to
safety nets to support the fulfillment of essential needs (Cooper Weil et al. 1990; UN 1995b; WHO 1995; AlMazrou et al. 1997; Heggenhougen 1999 Hallack 1999; Brunddand 2000). In the wake of globalization and
privatization, increasing attention must be paid to the role of non-state actors because they are now
influencing the health and well-being of people to an unprecedented extent, comparable even to the influence
of governments (UNHCHR 2000). The role of the state is to ensure that all human beings are guaranteed
their basic human rights, including the right to the highest attainable standard of health, whether this
obligation is fulfilled directly through government-run services or through private intermediaries.
Governmental roles and responsibilities fire increasingly' being delegated to non-state actors (e.g., biomedical
research institutions, health insurance companies, care providers, health management organizations and the
pharmaceutical industry) whose accountability lor what they do, do not do or should do about peoples health
is poorly defined arid inadequately monitored. There is today a universal need to reinforce the commitment
and capacity of governments to ensure that actions taken by the private sector and other actors in civil society
relevant to health .and other aspects of human development, both within and outside the boundaries of
nation-states,, are informed by and comply with human rights principles. Current structures are generally
insufficient for NGOs or governments to effectively monitor and hold corporations operating on a national
17
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scale accountable. This problem is compounded when these companies arc multinational (Hossain 1909,
Orford 1999; UNHCHR 2000).
Attention to health reveals that multinationals arc more than agents ol economic change whose
decisions are increasingly effecting the distribution of wealth, the fabric ol society and the creation ol
conditions favorable to advancing health; they are also increasingly the institutions called upon by political
and social forces to create and operate alternative mechanisms to extend health and social services and to
make available new and affordable vaccines and drugs (Kolodncr 1994). Yet because they arc multinational,
they largely escape the realm of legal accountability within states, and, while they may choose to adopt ethical
guidelines and codes of conduct, there is no international human rights law that direcdy applies to them or to
their actions. Today, the fora where world issues are debated have expanded from assemblies of
governments—for example, under the UN umbrella— lo galhennj's and congresses such as lhe Davos loium
that give a prominent role to these non-state actors, demonstraung that the stale and non-statc actors leading
the world economy have become inseparable partners. From a health and human rights perspective, the
desirable forms and extent of responsibility for multinational actors within the international legal system have
yet to be defined in ways that help to effectively shape international trade agreements and to ensure their
accountability. This is die next and most important challenge in the world of human rights, and it will have
far-reaching health consequences.
C. Strategic Directions to Better Health
Human rights can help to provide an approach for redefining the ways in which governments and the
international community as a whole are accountable for what is done and not done about the health of people
(Mann et al. 1994). This requires an understanding of the content of the health issues most relevant to the
health and well-being of individual and populations, as well as of those actions which ought to be taken at rhe
national level to move towards health development.
As the approaches set out by WHO are relevant to all its member states, tins discussion will be framed
around the strategic framework laid out by the WHO in its 1999 corporate strategy (WHO 1999c). From a
strategic perspective, the issues relevant to health development can be understood to lie along four
converging axes: (1) reducing excess mortality, morbidity and disability; (2) promoting healthy hfestydes and
reducing risk factors to human health that arise from environmental, economic, social and behavioral causes;
(3) developing health systems that equitably improve health outcomes, respond to people’s legitimate
demands and are financially fair; and (4) developing an enabling policy and institutional environment in the
health sector while promoting an effective health dimension to social, economic, environmental and
development policy. Each of these approaches will be briefly discussed below.
*(
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/. Reducing excess mortality, morbidity and disability
Recent WHO information reveals that six preventable or curable diseases cause 90 percent of infectious
disease deaths worldwide, as well-as half of all premature deaths, most of which occur in children and young
adults living in developing countries (Murray, Lopez 1996; WHO 1999a). Reduction of excesi mortahty,
morbidity and disability calls for a combination of sound health interventions—some of a clinical nature,
such as diagnosis and treatment of communicable and non-communicable diseases, and others building on
large scale programs to inform, immunize or apply population-based prophylactic therapies. From a health
and human rights perspective, it is worth recognizing that the growing health disparity between the North
and the South creates compelling needs both for every countiy to develop effective disease prevention and '
control programs targeted to their specific needs and for global sharing of technology7 and .resources in order
to enable poorer countries to accelerate progress in health development. Therefore, priority must be given
both locally and globally to poor and marginalized communities.
2. Promoting healthy lifestyles and reducing risk, factors to human health that arisefrom environmental, economic, social and
behavioral causes
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Modern public health recognizes the influence of external factors on the ability of individuals to adopt
healthy behaviors or to access care when ill health has set in {note to Editor: would suggest to cross reference to OTPH
chapter-on I lealth and Behaviors). As stated earlier, health promotion is the process of enabling people to increase
control over and improve their health. To do so, individuals or groups must be informed and able to identify
and realize aspirations, satisfy needs and change or cope with their environment. The concept of
interventions aimed at reducing risk is familiar to those working on such health issues as HIV/AIDS and
other sexually transmitted diseases, tobacco and other types of substance use or occupational hazards ( Mann
et al. 1992; Mann, Tarantolal996a, b; WHO 19()8d). Risk reduction interventions can also bring attention to
the inadequacy of public services to address such issues as reproductive health, access to safe blood
transfusion or access to clean water. Some authors have distinguished the notion of risk, defined as a
statistical probability of suffering from ill health, from that of “vulnerability,” which impacts on risk via
societal, program-related or individual factors (Mann, Tarantola 1996a, b; Tarantola 1998). Others have
further extended this analysis by defining “susceptibility” as the influence of external or individual factors on
risk and “vulnerability” as the degree to which individual, communities or nations are able to effectively cope
with the impacts of ill health (Barnett, Whiteside 1999). Still others have grouped these factors among the
“underlying preconditions for health,” including policy, legal and institutional environments, which have
traditionally been dealt with as a separate issue (Mann et al. 1994). All of these paradigms recognize the
importance of integrating morbidity’, mortality and disability reduction programs with interventions to
mitigate or address the factors underlying the occurrence of these events. Reducing susceptibility or
vulnerability requires, first, understanding who is affected and how and to what extent these people are
exposed to and able to cope with the factors that impact on their health, and then designing interventions
that can help enable them to cope effectively. From a health and human rights perspective, this process is
linked to the need to create conditions conducive to health through information, education and the
development or strengthening of health systems and social support programs that promote healthy behaviors,
impact on risk-taking behaviors and increase individual and collective commitment and capacity to engage in
these processes.
3. Developing health, systems that equitably improve health outcomes, respond to people's legitimate demands and arefinancially
fair
t
In this context, “health systems” can be understood as the set of public or private structures, services,
actions and people whose main aim is to promote health and prevent and treat disease. In order to progress
towards these, aims, health systems must be sufficiently accessible, efficient, affordable and of good quality
(WHO 2000b). The WHO World Health Report 2000 has proposed measures that reflect responsibility and
create the'grounds for accountability within health systems with regard to three dimensions of health: health
outcome, fairness and responsiveness (WHO 2000b). The responsibilities of health systems in relation to
health outcomes largely determines the type of services, interventions and technologies they offer. If analyzed
on the basis of health outcomes, the accountability demanded of health systems must take into consideration
the capacity of these systems to recognize and respond to health issues, as well as such factors as personal
behaviors or 'unforeseen social, economic or environmental situations or events. From an accountability
perspective, iris worth recognizing that some of these latter factors may impact on health outcomes but are
beyond the responsibilities assigned to health systems. They must be taken into account in other ways—for
example, in relation to governmental accountability for education, employment, freedom of movement or
association, or in relation to other rights that impact on health.
Underlying this attention to the responsibility and accountability of health systems is the concept of
equality, which implies that health systems arc capable of defining and recognizing the characteristics and
specific needs of populations within a nation who experience a disproportionate level of mortality, morbidity
and disability. This, in turn, requires that health data be collected and analyzed with a degree of sensitivity and
specificity sufficient to determine who is likely to require additional attention; what behaviors and practices
have to be supported, induced or changed; what service provisions have to be enhanced and in what ways;
and what financial mechanisms are necessary to provide the safety nets necessary to ensure that those who
need more actually receive more. Therefore, it follows that the information used to develop, monitor and
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evaluate policies and programs must accurately reflect characteristics that may be associated with
discrimination and inequality, including sex, age, rural/urban location and other relevant behavioral, social or
economic factors (Barton Smith 1998).
The WHO World Health Report 2000 proposes that “the way health care is financed is perfectly fair .
when the burden that health spending represents on the household, or its relative health financial
contribution is identical for all households, independent of their income, their health status or their use of the
health system” (WHO 2000b). Although the principle of fairness is not articulated as 'such in human rights
treaties, it builds on an array of rights, such as nondiscrimination, equality and participation, that, together
with obligations directly related to health, can be used to consider the responsibilities of governments for
health systems. The financing of health systems must, of course, be considered from the perspective of
competing human development priorities within a nation, as well as (hat ol (he intrinsic priorities within
health systems themselves. No global benchmark can therefore be propo>ed to establish (he minimum
national spending for health systems, whether from public or private sources, and the debate must remain
open as to the extent to which and the ways in which governments will invest in the, health of their
populations. Within healtla systems, the decisions concerning allocation of public funds fo!: specific health
initiatives can draw from epidemiological, economic or political considerations and can Use a variety of
methods and processes, including cost-effectiveness analysis, as well as human rights considerations. The
concept of financial fairness implies that these systems should enable all individuals to seek and receive
services that are commensurate to their needs and economically affordable.
Finally, the concept of responsiveness imposes on health systems a requirement that they be sensitive to
people’s aspirations, needs and demands with full respect for human rights, and that they offer‘support and
services. The principles of non-discrimination, protection of confidentiality (privacy) and respect for people’s
dignity are central to both the design of health systems and to the attitude and practices of health providers.
From a health and human rights perspective, each of the components considered necessary for health
systems to equitably improve health outcomes raises additional issues to be considered from the perspective
of governmental responsibility and accountability.
4. Developing an enabling policy and institutional environment in the health sector while promoting an effeclive health dimension
to social, economic, environmental and development policy
If it is clear that policies and practices within health systems may impact positively or negatively on
health, it is also clear that policies and practices concerned with the broad spectrum of human development
may also impact significantly on health status and health-seeking behaviors (Cooper Weil et al. 1990). A largescale industrial project may, for example, create selective migratory movements that may result tn accentuated
health hazards, whether these arc linked to inadequate working conditions, housing or social or cultural
uprooting (Shenker 1992; ILO 1996). The association between enhanced vulnerability to HIV/A IDS among
migrant laborers and economically motivated mobility in Africa and Asia provides one example (UNAIDS,
IOM 1998). Similarly, factors such as the amount of pollution that industries have generated, or the impact
that the use of pesticides in agriculture has had on the health of some populations, imply that health impacts
must be considered at all stages of human development programs (McMichael 1993). From a health and
human rights perspective, this requires attention to health impacts in the design of human development
programs; this would include preventing or counterbalancing their potential negative health effects, as well as
ensuring that health indicators are built into the monitoring of human development initiatives (WHO 1992;
Watson et al. 1998).
The four strategic elements of health as briefly described above provide a useful framework for
analyzing the interface between health and rights. Indeed, each of these elements involves governmental
obligations that are relevant to policies and programs directly impacting on health, as well as those more
broadly concerned with human development.
D. Health Development and Human Rights
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While the above categorization of strategic directions for health is useful because it reflects the approach
being taken by WHO and is guiding the current global health agenda, a perspective of governmental human
rights obligations towards health development emerges more clearly if these strategies are divided into the
following three domains:
I
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9
3.
The highest attainable standard of health. 'Phis is measured by morbidity, mortality and disability, by
positive health measures of growth and development in children and by demographic variables,
reproductive health, healthy lifestyles, behaviors and practices in adults. The focus here is on health
outcomes affecting individuals and populations.
Access to health systems which provide affordable and quality preventive, curative and palliative care
services and related social support. The focus here is on health systems.
A societal and physical environment conducive to health promotion and protection, including access to
education, information and other positive expressions of rights necessary for health as well as protection
from violence, environmental and occupational hazards, harmful traditional practices and other factors
that miiy impact directly and negatively on health. The focus here is on the societal and environmental
preconditions for health.
'Fhe development and application of governmental policies transcends all three of these domains of
health development and is equally relevant to governmental responsibilities both to promote and protect
health and to respect, protect and fulfill human rights (Roemer et al. 1990; UNDP 1998a). A systematic
analysis ol (he responsibilities ol governments lor health, considered with respect to their obligations under
international human rights law, begins to lead us towards the practice of health and human rights.
7. Recognizing the Reciprocal Impact of Health and Human Rights
There are two approaches to analyzing the relationship between health and human rights that help not
only to illustrate their connection, but also to provide a framework for considering the implications of the
health and human rights relationship for government responsibility and accountability (Mann et al. 1994). The
first focuses consideration on the ways in which health policies, programs and practices can promote or
violate rights in the ways they arc designed or implemented. By design, neglect or ignorance, health policies,
programs and practices in and of themselves can promote and protect or, conversely, restrict and violate
human rights. The second approach examines how violations or lack of attention to human rights can have
serious health consequences. The promotion, protection, restriction or violation of human rights all can be
seen to have direct and indirect impacts on health and well being. Looking at health through a human rights
lens means recognizing not only the technical and operational aspects of health interventions but also the
civil, political, economic, social and cultural factors that surround them. These factors may include, for
example, gender relations, religious beliefs, homophobia or racism, which individually and in synergy
influence the extent to which individuals are able to access sendees or to make and effectuate free and
informed decisions about their lives—and, therefore, the extent of their vulnerability to ill health. Thus,
health and human rights interact in numerous wavs, both direct and indirect (Ibid). Public health and human
rights each recognize the ultimate responsibility of governments to create the enabling conditions necessary
for people to make and effectuate choices, cope with changing patterns of vulnerability and keep themselves
and their families healthy. Using human rights concepts, one can look at the extent to which governments are
respecting,’ protecting and fulfilling their obligations for all rights—civil political, economic, social and
cultural—and how these government actions influence both the patterns of mortality, morbidity and disability
within a population and what is done about them
21
A. The Impact of Health Policies, Programs and Practices on Human Rights
A human rights framework can help to identify potential burdens on the lives of individuals and
populations that are created by health policies, programs and practices. An obvious example, as was
recognized in the ICPD Programme of Action, is demographic goal-driven family planning programs, which
may by their very nature violate basic human rights (ICPD 1994). More subtle human tights issues may arise
from health programs that fail to provide sendees to certain populations or are not appropriately tailored to
meet the needs of marginalized groups (Jackson 1998; Altman 1998; Wodak 1998; Bcyrer 1998; Stevens
1998).
Responsibilities for public .health are in ’large measure carried out through policies and programs
promulgated, implemented and, at the very least, supported by the state. Therefore, a human rights approach
to public health requires analysis of every stage of the design, implementation and evaluation of health
policies and programs. This section is intended to tease out some of the issues that a human rights analysis
can raise at various stages of policy and program design and implementation. IIIV/AIDS, sexual health and
reproductive health will serve as primary examples in this section because, in recent years, these issues have
been especially important in illuminating the impact that health policies and programs can have on human
rights.
Human lights considerations arise at the initial formulation of health policies and programs. Relevant
issues would be raised, for example, if a state decides to approach a health issue in a particular way but refuses
to disclose the scientific basis of its decisions or permit any debate on its merits, or if a government willfully
or neglectfully fails to consult with members of affected communities in reaching its decisions, or in any
number of ways refuses to inform or involve the public in policy or program development. Human rights
issues may also interact with the development of health policies and programs when prioritization of certain
health issues is based less on actual need than on existing discrimination against certain population groups
(Gilmore, 1996). This can occur when, for example, minor health issues that predominantly impact the
dominant group are systematically given higher priority’ in research, resource allocation and policy and
program development than other more major health problems. Restrictive laws and policies that deliberately
focus on certain population groups without sufficient data, epidemiological and otherwise, to support thenapproach may raise an additional host of human rights concerns. Two examples might be policies concerning
the involuntary sterilization of women from certain population groups that are justified as neccssaiy for their
health and well-being (Comite Latiamericano para la Defensa de los Derechos de la Mujer 1999; Lombardo
1996), and sodomy statutes criminalizing same-sex sexual behavior that are justified as necessary to prevent
the spread of HIV/AIDS (UNHRC 1994).
Human rights also need to be considered when choosing which data are collected to determine the type
and extent of health problems affecting a population, as this choice has a direct impact on the policies and
programs that are designed and implemented (Zierler et al. 2000).The choice of issues to be assessed and die
way in which a population is defined in these assessments are of primary relevance here (Braveman 1998). A
states failure to recognize or acknowledge health problems diat particularly impact a marginalized group, or
to consider the impacts of particular health issues on all members of a population, may not only violate the
ng it to nondiscrimination, but may also lead to neglect of necessary sendees, which in turn may adversely
affect the realization of other human rights (Cook 1994; Hendriks 1995; MiUer ft al. 1995). Examples of this
would include the almost complete lack of attention and resources devoted to the early detection of cervical
cancer by a number of governments, or state-controUed reproductive health programs that yxist for some
bUt exclude certain marginalized communities from their consideration ’and outreach
(WHO 1994b). Likewise, die scarcity or absence of HIV-related sendees in a number of places can well be
understood to have resulted in a disproportionate burden of health consequences that could have been
anTtteamie rtaUeVlated
slrnPle and affordable prevention messages and methods of early diagnosis
I
J
Once a decision is made that a particular health problem will be dealt with, human rights issues can
come into play in both die articulation and the implementation of the health policy or program. Programs
that provide contraception to young boys but deny access to young girls, with the stated rationale that access
might prompt girls to be sexually active, illustrate this point (Radhakrishna et al. 1997; Youth Research 1998).
22
I
From a human rights perspective, this distinction can be understood to be treating young girls unfairly and
unjustly on the basis of their sex. The prohibition of discrimination in the human rights documents does not
mean that differences should not be acknowledged, but rather that different treatment must be based on
reasonable and objective criteria (Cook 1992; Coliver 1995). Therefore, applying different approaches to girls
and boys in policy and programs development must be based on a vahd recognition of gender-related
differentials in risk and vulnerability with respect to the particular health issue and with an attempt to
minimize the influence of prescribed gender roles and cultural norms in making this determination (Holder
I
1992; Moody 1989).
, .
• 1; <
The severin' of the devastating tuberculosis epidemic in developing countries, and in marginalized
communities in'affluent nations, calls attention to the relevance of a hu^annnr^ts^nf1yS!>S f°r
implementation of a health policy and program (Raviglione et al. 1995; WHO 1999c).
L fssues
observed therapy strategy (DOTS) is widely recognized for its efficacy in controlling tuberculosi , the issues
raised by the very different wavs this strategy is administered in different countries and to different
population groups, demonstrates how discrimination may be relevant to the ways in which health programs
are implemented (WHO 2000a). Many health practitioners argue that the speed with which tuberculosis is
spreading and die potential impact of individual non-compliance to treatment are likely to^va‘e
spread of the disease and die currently observed prevalence of multiple-drug resistance (WHO 1998b). The
DOTS strategy is meant to combat this by enrolling patients diagnosed with active tubercu osis in a program
• where drugs are administered under the direct observation of a care provider, rather than self-administered by
the patient (WHO 1994a). The strategy requires frequent visits by patients to die site wiere rug .
Z'mXd which can potentially involve work absenteeism and in some cases out-of pocket trave
expenses In small communities, the strategy may also lead to breaches of the right to privacy, as frequen
visits to a 'treatment point may be associated wtth the stigma commonly attached to the disease. In cases o
non-compliance to regular treatment administered in this way, measures up to and including mandatory
hospital admission may be taken to motivate defaulting patients to comply. There is ample evidence to
suggest however, drat'in a number of places the level of coercion exercised by health practitioners in die
deefsion to apply DOTS, as well as in the application of mandatory instimtionahzation, is directly associat
with the levels of discrimination against particular population groups within the society in question (Farmer
al 1991 Bayei et al. 1993; Schmidt 1994; Efferen 1997; Heymannet al. 1991).
•
'
Attentioh must also be given to whether health and social services take into account logistic, financial
and soX-culmral barriers to access and enjoyment, as a failure to do so can result in discrimination in
I
practice if not in law (Focht-New 1996). This includes attention to die factors that may impact on sem
utilization such as hours of service and accessibility via public transportation. Issues are also raised by
decisions concerning die location of prevention and treatment services for certain health issues. An extreme
example relates to the location of STD diagnosis, prevention and care services which may be integrated
the reproductive health services generally available to women or else offered only in centers dedicated
STD
less likely to take
prevention and treatment. Evidence suggests that individuals, and women in particui ar a
and discrimination
I
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genetic disorders), or
Zther directly or because this information is intentionally or inadvertendy
.23
has in many places, led to loss of employment and housing, as well as harassment and verbal and physical
attacks (R. Cohen, Wiseberg 1990; Gruskin et al. 1996; UNDP1998b).
programs that are put
Decisions on how data are collected have a direct influence on d e pohcies and ,
into place. For example, differentials determined by sex ot gene cr r" cs '((v‘/s.ro tpK|cllU(>l.>gical data, nor
generally not systematically considered m the collection and analy. .
Q
1 ln countrles where the
are they sufficiently studied or built into the design o pr~ and car p
information is available as
........
specifi X as th se can have substantial health impacts (Freedman 1999). Examples include decisions by
rSStr^llold or block access to valid scientific information that would -able peo^ to
participate in the improvement of their health, avoid disease or claim and seek better care. Such i. the .
young women who become unwillingly pregnant or acquire sexually transmitted diseases beeause hey
denied information considered too sexually explicit for them-even though they became preg, ant: or
because they were in fact sexually active (Alan Guttmacher Institute 1998; Dowsett, Aggelton 1
).
»'•h“hT”‘V;
•S,. S, .„d i™. 4..
practices are valid from both a public health and a human rights perspecuve. The first step in
a"alyS1S
always be“o determine the stated justification for the measure-arid then to consider the framework set forth
m the “Siracusa Principles” mentioned earlier (UNECOSOC 1985). In analyzing health policies and
discriminatory
programs, as Jonathan Mann was fond of saying: “Assume aU health policies and programs
I
I
or restrictive of rights until proven otherwise.”
B. The Impact of Neglect of Violations of Human Right;s on Health
When health is understood to include physical, mental and social well being, it seems ^sonaWe to
conclude that the violation or neglect of any human right will impact adversely on health. While hi is
certainly true with respect to specific rights, such as nondiscrimination or education, the unpact ot neglect or
violation of rights is also compounded by the number of rights brought into question by any particu ai
situation. The health impacts of certain severe human rights violations, such as torture, imprisonment under
inhumane conditions, summary executions and disappearances have long been understood. Much work has
been done in this field, and efforts in this regard continue to expand. Such efforts include exhumations o
mass graves to ascertain how people have died and in what ways, the coding and matching ot genetic
information to reunite families separated during war and massive political repression, examination of ortur
victims to bring perpetrators to .justice and to assist with asylum claims, and entry into prisons and other
state-run institutions, such as detention centers, to assess health conditions and the health status of confined
populations. The impacts on health of these human rights violations can be both obvious and subtle. For
example, torture is a violation that causes immediate and direct harm to health. Yet only recently has the full
impact of torture begun to be recognized, including the hfelong injury to the victim, the effects on the health
of families and of entire communities and the transgenerational damage (Al 1983). lheie is increasing
recognition of the need to assess the duration and extent of the health impacts of such human ng its .
violations, including the direct and immediate impact of being subjected to torture oneself, but also its severe
and life-long effects on survivors and the trauma associated with being forced to witness summan
executions rape and other forms of torture and trauma perpetrated on others (Dawes 1990)
Health practitioners can—and in most cases do—have a strong positive mfluence on the promotion and
protection of human rights within the populations they serve. Yet violations of human rights perpetrated y
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24
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c
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I
health professionals regularly occur,•. These include not only such egregious examples as physician
participation :in torture and other severe violations of human rights, but also actions in the provision of
treatment anti care. For example, when care providers make decisions concerning patient access to available
prevention services, children with a chronic fatal disease or disability may be denied immunization against
measles and other preventable childhood infections (UN 1998b; Savage 1998; Ward, Myers 1999). In many
countries, rich and poor, patients with diabetes, carcinoma, chronic renal syndrome, mental disability,
hemophilia or other severe health conditions may receive a lower standard of care than others not only with
respect to the health issue in question but in general because their possibility of cure is regarded as limited
(UN1992b; Croftset al. 1997).
A less obvious impact of neglect of human rights on health concerns the many children from poor or
marginalized communities, where poor nutrition and ill-health prevail, that have a below-average school
enrollment and attendance rate and, as a result, lower-than-average educational attainment (Brundtland 1999).
’['he deprivation of these children from access to basic health sendees, coupled with the imposition of school
fees, leads to a limitation of their ability to exercise their right to education, producing lifelong effects on their
healtli and well-being.
In addition to the impact of egregious violations of rights on health, the more subtle effects of neglect
or violations of rights on health can also be considered. These would include exposures to ill health resulting
from violations of such rights as work, free movement, association and participation (Daniels et al. 1990;
Berlinguer er al. 1996). The impact of neglect or violation of factors considered to form the underlying
preconditions for health must also be considered. In addition to medical services, these have been understood
to include such factors as adequate housing, education, food, safe drinking water, sanitation, information and
protection against discrimination. Understood in human rights terms, neglect of these rights, particularly in
combination, can have serious negative consequences on health (Mann et al. 1994). No community is fully
protected from neglect or violation of rights and its detrimental consequences to individual and public health
(UN 1999a, b; Center for Economic and Social Kights 1999). In particular, gender-based discrunination poses
a pervasive threat to health. Girls and women who are denied access to education, information and various
forms of economic, social and political participation are particularly vulnerable to the impact of
discrimination on their health. This is true when discrimination is recognized, tolerated, acknowledged or
even condoned by governments, but also when it remains insidiously hidden or deliberately ignored behind
an accepted status quo (Sullivan 1995; Dixon-Mueller 1990).
One example, drawn from the world of reproductive health, dramatically illustrates this point. There is
now general acknowledgement that violations of human rights, including systematic gender discrimination,
create an environment of increased risk in relation to women’s health (Cook 1995; Berer 1999). In this
context, it is necessary to consider those factors that are understood to influence directly the reproductive
health of women. Access to information, education and quality services is critical, as are services adequately
targeted to respond to the needs of women of different ages and from different communities. Underlying all
of this is the impact that gender roles and gender discrimination have on both health status and service
delivery (Doyal 1995; WHO 1998a). The relevance of human rights to this analysis becomes clear when
considering the gaps and inequalities in sendees and structures in relation to the social roles that construct
male and female identity. Equally important is how these factors play out at the policy and program level in
terms of reproduce c health research, policy, financing and service delivery. Traditional public health focused
on the need for information, education, contraception, counseling and access to quality services. These
elements of health practice were, and still are, central to improving women’s reproductive healtli. However,
even if these services are available, an individual woman has to be able to decide when and how she is going
to access these services. This implies that she has to have the ability to control and make decisions about her
life.
In the above example, considering the impact that violation or neglect of human rights has on health
highlights the societal context that would hinder or empower: an individual woman’s ability’ to make and
effectuate the free and informed choices necessary for her reproductive health. From a broader policy and
program perspective, this insight reveals that linking the human rights framework to health implies
recognizing that individual health is largely influenced by one’s environment. This means that the integration
of human rights in the design, implementation and evaluation of health policies and programs is necessary
25
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P°s
not only because of a government’s human rights obligations, but also in purely pragmatic public health
terms. Thus, attention to the civil, political, economic, social and cultural factors that arc relevant to a
person’s life, such as gender relations, racism or homophobia, and the ways this combination of factors
projects itself into who gets ill and what is done about it, is central to sound health and human rights practice.
Because of the multifarious effects on health of human rights neglect or violations, the process of
documenting evidence on the health impacts resulting from violations or neglect of human rights must be
thorough and thoughtful. The involvement of communities that are disproportionately affected by human
right violations in the development, implementation and monitoring of decisions affeciing them is crucial to
mitigating these impacts. Affected individuals working together in defense or advocacy groups—be they
concerned with breast cancer, diabetes, renal syndromes, hemophilia, chronic disabilities or other health
issues—have been effective in bringing to light some of the more subtle mechanisms that come into play in
linking health status with the human right violations to which people are subjected (Steingraber 1997;
UNAIDS 1999).
8. Optimizing Health and Human Rights in Practice
A crucial step in optimizing .the relationship between health and human rights is to conduct a systematic
review of how and to what extent governmental policies and programs are respectful of human rights and of
benefit to public health. Such a review, presented below in Box 2, is proposed as a critical first step in
improving new and existing policies and programs through assessment of their validity, applicability and
soundness, while addressing their practical implications from both human rights and public health
perspectives. The suggested questions can be used by policymakers and public health and other government
officials to help in the development, implementation and evaluation of more effective policies and programs,
and by non-governmental organizations and other concerned actors as an advocacy tool to hold governments
accountable for the ways they are and are not in compliance with their international legal obligations to
promote and protect both public health and human rights.
i
Box 2. Issues to be Addressed in Assessing Policies and Programs
Thefollowing questions may serve as a starting point to help guide this analysis:
•
What is the specific intended purpose of the policy or program?
•
•
What are the ways and the extent to which the policy or program may impact positively and negatively on health ?
Using the relevant international human rights documents, what and whose rights are impacted positively and negatively
by the policy or the program?
•
•
Does the policy or program necessitate the restriction of human rights ?
Ifso, have the criteria/preconditions to restrict rights been met?
•
•
Are the health and other relevant structures and services capable of effectively implementing the policy or program?
What system ofmonitoring, evaluation, accountability and redress exist to ensure that the policy or program is
progressing towards the intended effect and that adverse effects can he acted upon? (Gruskin, Tarantola, in press)
The importance of the human rights framework to policies and programs is that it can pro\ ide a method
of analysis and a framework for action, winch can then be used to help shape specific interventions aimed at
reducing the impact of health conditions on the lives of individuals and populations. This approach requires
working with the international human rights documents to determine the specific rights applicable to a given .
situation, and then considering how and to what extent morbidity, mortality, disability, risk behaviors and
vulnerability to ill-health are caused or exacerbated by insufficient realization of human’ rights. This analysis
will be most effective if done in partnership with people with substantive knowledge of human rights.
26
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A second level of analysis can be created by recognizing the convergence of the three health domains
described in Section, VI (health outcome, health systems and underlying conditions for health) with the three
levels of governmental obligations that exist for each right—respect, protect and fulfill. (Figure 1) Healt
practitioners will find this table most relevant to their work if they use the suggested health domains (first
column) as their entry point and dien move to the right, seeking to identify how each level of governmental
obligation can influence health poheies and action within each of the three domains. Ulumately, such an
analysis could be extended to examine how those approaches recognized as best health pracuce in each oft e
three domains could contribute to the advancement of human rights with respect to each level of
governmental obligation. The issues raised in the boxes below are not meant to be highly detailed, but simply
i
1
to serve as examples of the issues this approach brings to light.
Figure 1. A Pathway to Health and Human Rights13
I.
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Governmental obligations
With respect to human rights
Domains of
health
1.
Health outcome
I
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Fulfill________
Protect______
Respect______
Government
to
take
Government to
Government not to
administrative,
prevent non state
violate rights of
legislative, judicial
actors (including
people on the basis
and other measures
private health care
of their health status
to promote and
structures and
including in
protect the rights of
insurance
pr(.)viders)
information
people regardless of
from
violating
rhe
collection and
their health status,
rights of people on
analysis, as well as in
including the
I
the basis of their
the design and
generation of data
health
status
provision of health
concerning health
including
in
the
and other services.
outcomes for use in
provision of health
guiding health
and other services.
policies and the
provision of health
and other services,
as well as providing
legal means of
redress that people
know about and can
access._
H Adapted from •raran,oh.n..Gr7k1n, S. (1998). (dnldren confronring HIV/AIDS: charting the confluence of rights
and health. Hc-altb and H/i/mm Rights, 3(1), 60-86.
27
ex
2. Health systems
3. Societal and
environmental
preconditions
Government not to
violate rights directly
in the design,
implementation and
evaluation of
national health
systems, including
ensuring that they
are sufficiently
accessible, efficient,
affordable and of
good quality for all
members of the
population.
Government to
prevent non-state
actors (including
private health care
structures and
insurance *
providers) from
violating rights in
the design,
implementation and
evaluation of health
systems and
structures, including
ensuring that they
are sufficiently
accessible, efficient,
affordable and of
good quality
Government to take
administrative,
legislative, judicial
and other measures
including sufficient
resource allocation
and the building of
safety nets, to ensure
that health systems
are sufficiently
accessible, effn. lent,
affordable and of
good quality, as well
as providing legal
means of redress
that people km >w
about and can
access.
Government not to
violate the civil,
political, economic,
social and cultural
rights of people
directly,
recognizing that
neglect or violations
of rights impact
directly on health.
Government to
prevent rights
violations by non
state actors,
recognizing that
neglect or violations
of rights impact
directly on health
Government to
take all possible
administrative,
legislative, judicial
and other
measures,
including the
promotion of
human
development
mechanisms,
towards the
promotion and
protection of
human rights, as
well as providing
legal means of
redress that people
know about and
can access.
The questions proposed in Box 2 may be used to create an agenda for action to help guide the analysis
of governmental obligations for health outcomes, health systems and the societal preconditions for health
proposed in Figure 1. Human resource development in support of health requires that health training include
the skills necessary to document and measure the health effects of neglect or violations of rights. Education
and training of people working in human rights should likewise provide them with the skills necessary to
analyze the complex relations between neglect or violation of rights and their health impact; in jsuch a way
t at the information provided can be used to monitor and ensure government accountability. This joint
approach is necessary if the health and human rights framework is to be practical and useful. Only when the
many dimensions necessary for health are described, measured and named in human rights terms can the full
extent of the relationship between health and human rights be realized. Such a review offers a critical
approach to assessing the validity, applicability and soundness of new and existing policies and programs, and
to addressing their practical implications from both human rights and public health perspectives. Through
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this approach, the disctplines of health and of human rights come together most visibly, and national capacity
building to ensure reasoned and sound analysis becomes a necessity.
..
Another dimension of developing the health and human rights relationship is the application of
mechanisms, methods and tools to monitor progress and shortcomings in implementation of health and
human rights at the national and international level. An earlier section described the role of treaty bodies in
engaging in dialogue with governments on their degree of compliance with their international lega
obligations WHO, for its part, is developing monitoring methods and indicators that, although techmcaUy
not binding on governments (with the exceptions of reporting under the International Health Regulations),
set out international norms by which member stales commit to abide m principle after passage at the World
Health Asstemblv In the past, WHO’s attempts to measure health on the national or international level
selectively used morbidity, mortality and disability indicators. Tins exercise was severely constrained by
incomplete national data, differences in measurement methods across countries and, even more importantly,
an inability’ to relate health outcomes to the performance of health systems. Furthermore, most of these
indicators were applied at a national, aggregate level with insufficient attempts to disaggregate the data
collected to reveal the disparities that exist within nations. It has been understood that measurement
indicators and benchmarks that focus on the aggregate (national) level may not reveal important differentials
1
that may be associated with a variety of human rights violations—in particular, discrimination^
In order to improve the knowledge and understanding of health status and trends and to relate *e
trends to health system performance, WHO has developed the tollowing five global indicators (WHO
2(.)l)()b):
1.
1 lealthv life expectance: a composite indicator incorporating mortality, morbidity and disability in a
disability-adjusted hie years measure. This indicator will reflect time spent in a state of less-than-full
2
Helldi inequalities: the degree of disparity in healthy life expectancy within the population.
3
Responsiveness of health systems: a composite indicator reflecting the protection of dignity a"d
confidentiality in and by health systems, and people's autonomy (i.e. their individual capacity to effect
informed choice in health matters).
, • •
o
Responsiveness inequality: the disparity in responsiveness within health systems, bringing out issues of
4.
5.
low efficiency, neglect and discrimination.
. .
Fairness in financing: measured by the level of health financing contribution of households.
WHO has stated that it will collect this data through bmlt-in health information systems, demopapluc
and health surveys (DI IS) conducted periodically in countries and other survey instruments. Data wiU thus
analyzable by sex, age, race/birth (if warranted under national law), population groups (e g., indigenous
Dooulations) educational achievement and other variables.
.
.
P
WHO has also expressed its commitment to working with countries towards increasing their capacity
collect the above mil rmation and, additionally, to determine additional data and targets that may b
ecifc
suited to country-specific situations and needs. WHO and other institutions concerned^w
SX -c s ted their desire to use these data to assess trends in the performance of national health
systems inform national and international policies and programs, make comparisons across countries and
’ill Upnlth This nrocess is also intended to support the development of national benchmarks
ZZ nrZ wrll be set by individual governments with a view towards being able to compare their own
health system performance with others, and to compare among regions and over ^eThese benchmarks
developments,
■iance with their human rights obligations, are promising steps for the future
governmental compli
development and application of .he health and human rights framework.
,
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9. Conclusion
This chapter has outlined the health and human rights framework as a pathway towards enhancing the
value and impact of health work by health policy makers, program developers, practitioners, and students. It
is hoped that increased attention to this fundamental relationship can open new avenues to human
development, and by so doing, marshal new resources towards improving individual and population health.
Keeping in mind the tools proposed in die previous section, there are three levels on which this new svnergv
can be recognized, applied and monitored. The first concerns the development of adequate monitoring tools
reflecting both health and human rights concerns; the second, the application of the health and human rights
framework to health practice; and the third, the creation of a significant research agenda lo advance our
collective understanding of the health and human rights relationship.
First, on the level of health best practice and international human rights law, evidence-based health
policy and program development can be guided by a systematic human rights analysis. This process involves
significant efforts to ensure that the information that is sought, collected and analyzed brings attention to
both trends and disparities, and that this information is used to address these gaps. This would include
attention to the relative successes and failures of progress achieved towards global goals, such as those to
which countries have subscribed in such forums as the World Health Assembly or through the international
conference processes.
It is of critical importance that WHO and the human rights treaty bodies are currently and
simultaneously engaged both in the process of setting out global indicators and in defining approaches
towards the development of country-specific benchmarks consistent with international knowledge, practice
and experience. The prevailing state of health and resource availability within individual countries must,
nonetheless, be taken into account to allow trends and disparities to be measured in relation to individual
benchmarks. While the existence of this work is encouraging, there is a need to further develop, test and
apply indicators that capture the disparities that may prevail within a population, as well as those that can
begin to suggest the differences between government unwillingness and incapacity. Relevant indicators have
been developed in the economics field, where the Gini coefficient, for example, is used as a measure of
economic heterogeneity within a population (Kennedy et al. 1998). Disaggregation of data would allow the
attributes on which discrimination is often based, including sex, age, prior health status, disability’, birth or
social status, to be taken into account. Policies and programs could then aim to advance the health of
populations by setting out higher goals for the population as a whole, while bringing increased attention to
reducing the gaps between those who enjoy better health and better services and those who, for political,
civil, economic, social or cultural reasons, arc more xmlnerablc to ill-health and to inadequate services and
structures.
The second level on which health and human rights are beginning to converge is in ensuring that health
systems and practice are sufficiently informed by human rights norms and standards. Sound formulation and
implementation of health policies and programs must seek to achieve the optimal balance between the
promotion and protection of public health and the promotion and protection of human rights and dignity.
Processes to arrive at this optimal balance can be built within national systems on the basis of the approach
proposed in the previous section, incorporating evidence collected in the ways suggested above and through
participatory dialogues between decision-makers with experuse in public health, those with expertise in
human rights and concerned populations. The realization of such an approach requires additional efforts to
create consultative mechanisms, as well as education and training in health and human rights.
Finally, the third level of convergence between health and human rights lies in the broad need for
further research. Given that human rights are established, internationally agreed-upon norms to‘fwhich states,
lave subscribed, the reciprocal impacts between human rights and health must be further researched and
ocumented. There is a national and international obligation to increase research and documentation, as well
as to conceptualize and implement policies and programs that fully take these connections into account. The
utility of this research will largely be predicated on the extent to winch those with experuse in health
collaborate with people knowledgeable about human rights in the
the conceptualization
conceptualization of
of their
then research agendas
and in the steps necessary for carrying this work forward.
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$6
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The challenges posed in linking health with human rights are immense. There is, however, increasing
evidence that public health efforts that respect, protect and fulfill human rights are more likely to succeed in
public health terms than those that neglect or violate rights. National and international policy and decision
makers, health professionals and the public at large all, to varying degrees, understand the fundamental
linkages between health and human rights, and the way in which those linkages can provide new ways to
analyze and conceive responses to health issues. To move the work of health and human rights forward will
require building and strengthening the information and education available about human rights concepts and
procedures. It will also require information exchange and stronger cooperation between those working on
health and those working on human rights. Wlien people are sufficiently knowledgeable about human rights,
they will be able to identify the issues for which the synergy of human rights and health is critical, and to act
accordingly. Human rights and health are progressing, in parallel, towards a common goal that will never be
fully realized. Yet, together, they project a vision and an approach that may fundamentally and positively
improve the lives of people everywhere in the world.
I
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‘dXJ: S KSiXXJo.
WHA51/5 adopted bv the fifty-first World Health Assembly, Geneva, 1998.
World Health Organization (1998d). Tobacco Free Initiative. Executive Board, Provisional Agenda Item 3,
103rd Session, EB103/5.
wnTon
World Health Organization (1999a). Removing obstacles to healthy development. WHO Report on
Infectious Diseases, WHO/CDS/99.1.
,
World I Icalth Organization (1999b). IFHO eo^omte strate^for the IF HO Secretariat. Executive Board
Provisional Agenda Item 2, 105lh Session, EB105/3. WHO, Geneva, 11-17.
World Health Organization (1999c). The vorld health report 1999-niaking a difference. Geneva.
World Health Organization (2000a). The economic impacts of tuberculosis. Ministerial Conference, the Stop 1B
Initiative 2000 Series WHO/CDS/STB/2000-5.
World Health Organization (2000b). World health report—2000.
World Health Organization (2000c). Informal consultation on mainstreaming human rights in WHO, 3-4
XX o^Heakh Organizmion and the Joint United Nations Programme on AIDS (UNAIDS) (1999).
I
I
Consultation on HIV/AIDS reporting and disclosure, Geneva, 20-22 October 1999.
Youth research (1997). Naked wire and naked truths: a study of reproductive health risks faced by teenage
Y°Ugul7in I loniara, Solomon Islands.16, 11-12^
Zicrlcr S Cunningham, W.E., Andersen, R., Shapiro, M.F., Nakazono, T„ Morton. S, et al. (2000^ Violence
vKtimization after I IIV infection in a US probability sample of adult patients in primary care. Ameman
Journal of Public Health, 90(2), 208-15.
I
5
39
ur
Orientation/Training Program on “Health as a Human Right towards realizing Health for All”
I
Session 2 Understanding the political economy of health and Social Determinants of Health
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Community Health Cell, Bangalore
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People S Health Assembly
...4ASi
Table of Contents
1 The Political Economy of the
* Assault on Health
Mohan f^ao and fc&nc L-o&/v&n^on
1
I
O Equity and Inequity today:
some contributing social factors
NaJinC' (jTia^man anc/ Ma/inc Itart
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Cover picture taken from Health for the Millions,
Sept-Oct, Nov-Dec 1997
D The Medicalization of Health Care
and the Challenge of Health for All
PaviJ c,>anJc.r^
A, The Environmental Crisis:
threats to health and ways forward
NiUa<; ftall^ivorvi
C Communication as if People Mattered:^/5'
& adapting health promotion and
social action to the
global imbalances of the 21st century
PaviJ We-me-r
Layout and design by Janet-Maychin
PHA bACKGkOUAiD PAPER!
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These are five background discussion papers for the People’s Health Assembly. The papers are draft versions. We would
ike you to discuss the papers, suggest additions or changes, and identify points where you may disagree. We would also
ike you to use the papers as a starting point for the identification of your own stories and case studies that you think
illustrate some of the issues brought up (or others that you come to think about!).
At the end of the paper you will find a list of action points. Please add to this list, which we will use as an input for the
Peoples Charterfor Health which is currently being formulated.
Please submit your comments, stories and suggestions for action to the analytical drafting group coordinator
Nadine Gasman, Fuente de Emperador 28, Tecamachalco C.P. 53950, Estado de Mexico. MEXICO.
‘
Teh 52-52-510283, Fax: 52-52-512518, e-mail: giLsmanna@netmex.com If you have acccess to the internet, you should
be able to find other PHA papers and the People’s Charter for Health primer on the address www,pha2000.org
For more information on the People’s Health Assembly, please contact:
PHA Secretariat, Gonoshasthaya Kendra, PO Mirzanagar, SaivarCantt. Dhaka 1344, Bangladesh
e-mail: phasec@pha2000.org: website: www.pha2000.org
Peqjle's Health Assarbly
J
The Political Economy
r
ii
of- tri€'
97
ssau
oh Health
by Mohan l^ao anJ ^s-ne- L^e-we^n^on
Executive Summary
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I
he world has never before been richer than it is
today. Yet large populations of the world
find themselves without adequate re
sources to provide for basic needs to remain
healthy. While health indices like life expect
ancy has increased,,and mortality in general • •
and infant mortality rates in particular
have decreased on average, the rates of
improvement in these indices have de
clined in'the last two decades. Indeed in
many countries across the globe, there have
been inct-easi’S in Irvcls of infanl and child „
mortality oven as life expei lancy has
declined.
Inequalities between and within countries
have widened sharply. While a small
proportion df the world's population is
becoming increasingly wealthier, unem
ployment. loss of assets and deprivation
health For the millions, sept-oct. nov-dec 1997
are increasing in a widening share of the
world’s communities, including the poor in rich countries.
These changes, moulding health and guiding health policy, are consequences of the manner in which
structures of ownership, production and distribution of the world’s wealth have been systematically
changed over the last two decades. This paper traces some of the influences and factors which together
have shaped policies across the world, drawing attention to the manner in which they impinge upon
health and affect health services.
Economic policies around the world are being shaped by international financial institutions, in particular
the International Monetary Fund (IMF) and the World Bank (WB). These neo-liberal policies are charac
terised by reducing the role of the state and increasing that of market forces. Globalistion, privatisation
and liberalisation form the heart of this package of policies.
Third World countries indebted to international financial institutions are pressurised to implement the
set of policies under the Structural Adjustment Programme (SAP). SAP policies applied in a uniform
manner across the globe has increased indebtedness of these countries and accelerated the transfer of
resources Irom poor communities and nations to rich ones. I hey have also had profound social conse
quences. They have led to the collapse of weak and under-funded systems of public health even as they
increased levels of hunger and poverty, and thus diseases.
These SAP policies have also had profound political consequences as nation states implementing these
policies have been weakened. At the same time multinational corporations (MNCs) have become increas
ingly powerful, controlling an increasing share of global resources. The free flow of speculative finance
across borders in search of quick profits, have left a trail of devastation in people's lives.
In order to reclaim people's health it is necessary to address these wider issues of disempowerment,
address issues of equity and participatory democracy, and for rebuilding national priorities with a focus
on the needs of the majority of the population.
The Pelitical Etcrcrry of die Assault cn Health
i
#e
80
T
P00reSt 20% COmmand merelV 1%. More than
T 55 ‘n ,n°W W ,Per fapi,a inCOmeS l0W1''
lh('y I'tnl tt dettKle
ago. 55 countries, mostly tn sub-Saharan Africa. Eastern Emope and the
capiTncomes
‘"dePendent Slates <CIS>' ha™ had declining per
access to health services, and 2.6 billion to basic sanitation. Although
people are living much longer today, around 1.5 billion are not expec ted
SahaTIf0 380 ■|l"Ci"'d lifC l'xPccla"‘'.y i" wine countries ol s',I,
oanaian Africa is only around 40 years.
ne\i mlenntioiuilist.
«.nd !»» . .........
l”""
Introduction
he world has never before been richer than
it is today. Yet large populations of (he
world find themselves without adequate
resources to ensure good health.-Despite the
unprecedented advances in medical technology,
around 800 million people lack access to appropri
ate and affordable health services. While life
expectancy has increased—and mortality in
general and infant mortality rates in particular_
have decreased in most countries, the rates of
improvement in these indices have declined in the
last two decades. Indeed, in some countries, (here
has.been an increase in levels of infant and child
mortality. In other words, the increased opportuni
ties for health have been distributed highly un
equally around the world.
Inequalities between and within countries have
been widening to levels seldom before witnessed.
Unemployment, landlessness, loss of assets, and
deprivation are increasing in a widening share of
the world’s communities. At the same time pov
erty has spread even within rich countries. To
gether, these factors profoundly affect the health of
large sections of the population of the world.
Such factors are not an accident, but the conse
quence of the way in which structures of owner
ship, production and distribution of the world's
wealth have been systematically changed over the
last two decades. This paper briefly attempts to
delineate some of these < hanges while drawing
attention to the manner in which they impinge
upon health and influence health services organi
sation.
Ffecple's Health Asserrbly
H/.W
reeopt history
of economic policies
owards the end of the 1970s the long boom
of post-war economic growth ground to a
halt. Economists hesitated to use the term
depression’ to describe this phenomenon since it
brought back memories of the 1930s. a period that
had plunged the world info the horrors of fascism
and I he 2nd World War, but the 'recession' of the
1980s was similarly widespread and deep These
changes look place together with the collapse of
the Soviet Union and the state-controlled Econo
mies of the socialist world. They also led to a
reshaping of the capitalist world, particularly'the
pursuit of market policies and (he opening of
countries to transnational corporations (TNCs)
through a complex of changes known as !
I
globalisation, privatisation and liberalisation.
The- dsb-t cnsls
T n the 1970s—and particularly following the
I rush of deposits in the wake of the oil-price
increase private Western banks encouraged
countries in the Third World to borrow extensively
Io finance large-scale development projects.
Indeed, so acute were the problems of uninvested
capital that the banks resorted to bribing politi
cians and influential officials in the Third World to
make commitments towards these projects, many
ol which were otherwise unviable. The projected
returns failed to materialise, however, interest
rates rose sharply. By the early 1980s. large num-
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Your ooNmoH
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alism, competitive wealth-seeking and conspicuous consumption. Along with the decrease of
• community values has become the undermining of
" public initiatives and institutions, especially those
that serve and protect the interests of the poor. In
this ideology, public intervention and institutions
are necessarily inefficient and wasteful, and
markets the best way to both economic growth
and overall development. Economic growth, it was
maintained despite extensive evidence to the
contrary, would trickle down to the less fortunate
and thus result in overall development.
i
he contradiction between the
prescription to the third world and the
economic success stories
bers of now heavily indebted countries were
unable to pay back their loans.
It was at this point that the International Monetary
Fund (IMF) stepped in to bail out the Northern
banks by offering loans to the indebted countries.
The loans were primarily aimed al preventing the
collapse of the private banks; they also served to
involve the borrowing countries in a new frame
work of regulations in the economy, ostensibly
aimed at improving their efficiency and competi
tiveness in the world market.1 Thus the restructur
ing of Third World economies to ensure debt
repayment began to drive economic policy.
1
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AJeoHberaUso®
ver the same period, right-wing eco
nomic policies took centre-stage in the
USA and the UK. These policies, de
scribed variously as Reagonomics. Thatcherism or
monetarism, reflected an ideological commitment
to unbridled market principles, ignoring the
remarkable role in these countries of state-directed
economies. One of the significant lessons of post
war economic growth had been the singular role
that the state could play, and indeed needed to
play, in capitalist countries in order to avoid
recurrent periods of crisis due to falling demand
For instance, state involvement in public health
had been al the heart of the strategy to stabilise* the
economies, in a move to help capital growth and
technological change. In the new environment of
the 1980s, these policies (Keynesian) came under
systematic attack from neo-liberal economists.
Reducing the rale of the state and increasing that
of market forces, irrespective of their social and
long-term economic costs, were at the centre of (he
new model of economic growth. This was accom
panied by the triumph of the ideology of individu-
‘The great post-war economic success stories of capi
talist countries, with the rarest exceptions (Hong Kong),
are stories of industrialisation-backed, supervised,
steered, and sometimes planned processes managed by
governments: from France an’d Spain in Europe to Ja
pan. Singapore and South Korea. At the same time, the
political commitment of governments to full employ
ment and—to a lesser extent—to the lessening of eco
nomic inequality through, a commitment to welfare and
social security explains part of the success4
’The greatest of neo-liberal regimes, President
Reagan's in the USA. though officially devoted to
fiscal conservatism and “monetarism", in fact used
Keynesian methods to spend its way out of the
depression of 1979-82 by running up a gigantic
deficit and engaging in equally gigantic armaments
build-up. So far from leaving the value of the dollar
entirely to monetary rectitude and the market,
Washington after 1984 returned to deliberate man
agement.' 5
^tartajisl
dSt/TOpt
P rogrammes (SAP)
t the height of her economic and political
/ \ power in the new unipolar world, the
VUSA— assisted by the Bretton Woods in
stitutions (World Bank and International Monetary
Fund)—found a way out of the impasse of falling
rates of profit and increasing unemployment by
opening-up potential markets in Third World coun
tries.
k
The debt situation of these countries became the ve
hicle for introducing a set of policies brought together
under the rubric of structural adjustment pro
grammes (SAPs). Future loans from international
financial institutions and access to other donor funds
and to markets, became henceforth linked to accept
ing this broad package of macro-economic policies.
!
The Political Etomy of the Assault cn Health
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— I —ho structural adjustment programme (SAP)
I
package comprises essentially the following
Lx- measures:
3» trade liberalisation removing the protection to
local industry;
3>: reduction of import-export - tai iffs.
Ol lio
335 deregulation of the economy with fewer
controls on foreign investments;
3K abolition of price controls;
3» removing the protective barriers to outflow ol
funds;
38 cuts in government spending including funding
of social sectors;
devaluation of currencies to achieve export
competitiveness;
s>: deregulation of labour laws and retrenchment of
workers;
3» cuts or removal of social subsidies; and
3» public sector enterprise reform' typically
through privatisation
It was believed that by adopting this package of
policies, indebted countries would not only attract
foreign investments but would also be in a posi
tion to pay for them by increasing their exports of
primary commodities. The free flow of funds
across borders, it was believed, would facilitate
this process. At the same time, removing public
subsidies and cutting public spending would
enable indebted countries to mobilise larger funds
for investment. Providing a stimulus to the private
sector by loosening regulations and controls
would provide the necessary stimulus to this
sector to act as the engine of economic growth.
SAP, liberalisation and privatisation measures
were applied in a uniform manner across three
continents, beginning with Latin America and
Africa in the early 1980s and in Asia in the late
1980s.
In the agricultural sector this led to a reinfon ement of colonial patterns of agricultural produc
tion, stimulating the growth of export-oriented
crops and reducing the production of food crops.
The problem at the heart of this pattern of produc
tion was that it reinforced the pre-existing interna
tional division of labour and that it was imple
mented when the prices of primary commodities
inM^i
exported by Third World countries were low as
never before. The more successful the countries
were in increasing the volume of exports, in
competition with other Third World countries
exporting similar products, the less sudeesqful they
were in raising foreign exchange to finance their
imports Thus many countries shifted backwards
into being exporters of unprocessed raw materials
and importers of manufactured goods, in keeping
with the saying 'produce what you don t consume
and consume what you don't produce'. Indeed as
the range of products consumed by. households in
the South shrank, the acronym SAP increasingly
came to be given new meanings; 'See And Pass or
'Suffer And Perish'.
In the industrial sector, where the countries had
been striving to break out of colonial patterns of
dependent development, the withdrawal of state
support plunged many enterprises into crisis. Such
units were then allowed to close or were priva
tised or handed over to TNCs. typically with
significant losses in employment. Just as the state
reduced its commitment to critical sectors such as
education and health, so also the free flow of
capital across borders in search of labour. law
materials and markets weakened the state. Fur
ther, over this period, capital across the globe was
increasingly being concentrated in fewer and
fewer hands with an explosion of mergers and
acquisitions.
Together these policies and processes increased
indebtedness, increased the rate of exploitation ol
low-income communities across all countries, and
shifted wealth from productive to speculative
financial sectors where boom and bust became the
order of I he day. Many countries opened export
processing zones (EPZs) to attract foreign invest
ment. driving down their own labour costs and
forgoing tax revenues. I’suallv exempt from
national labour laws. EPZs employed women in
low-paid jobs, while tax concessions made it
difficult for national governments to meet the
long-term social costs of production incurred in
these zones. Thus these policies also led to a
significant increase in casual, poorly-paid and
insecure forms of employment, and led to the
collapse of already weak and undei funded sys-
Ffecple's Health Assembly
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tems of health, education and food security. They
increased poverty in already poor countries even
as a few people became richer and the middle and
upper classes obtained access to consumer prod
ucts manufactured in the rich countries.
ing proportion of families were pushed under the
poverty line, and women and girl children were
disproportionately affected. Morbidity levels
increased even as poor people were increasingly
unable to access health institutions, which, under
the reform measures, typically introduced payment for services. Given increasing levels of
Changes in food prices induced by SAP: Bolivia 1975
malnutrition, it is not surprising that infant and
and 1984
child mortality rates, which had hitherto
Food item
Hours worked to purchase 1,000
shown a decline, either stagnated or in fact
_________ calories in
increased in a number of poor communities.
1975
1984
Barley
0.07
0.59
The growth promised by the initiation of SAP
Sugar________
0.40
_ 9.1b
measures was particularly not achieved in
_ ~0.17
Corn
0.64
Africa, which has shown reduced economic
Wheat flour
0.21
0.52
3.47
growth for more than two decades now. Per
Dried beans
0.22
0.22
0.48
Rice_________
capita income for sub-Saharan Africa as a
Bread________
0.28
0.51
whole is lower than it was in 1960. It is thus not
0.28
0.51
Oil__________
surprising that these last two decades are often
0.29
1.38
Dried peas
described as lost decades for these countries.
0.76
135
Potatoes _
'___ i .02
3.22
, Onions______
I Powdered milk
1.05
3.95
St/iinr: Susan George. A Fate I'l' wse Shan Debt: The World Financial
( risis and the Toor. /’IFG. New Delhi, HHK). /z/Jz*
Concentration of
power
I
One consequence of these processes has been
commonly described as the feminisation of pov
erty. as females increasingly had to strive to hold
families together in various ways. More women
entered the paid labour force, typically at lower
wages and with inferior working conditions than
men. Simultaneously, the extent of unpaid labour
in households (predominantly performed by
women) increased as public provision of basic
goods and services declined. Young children,
especially girls, were increasingly withdrawn from
school to join the vast and underpaid labour
market or to assist in running the household. The
involvement of children and adolescents in crime
and delinquency increased under these circum
stances. Rising food prices meant that an increas-
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lobal changes in production technolo
gies and in the organisation of pro
duction have also taken place, with
fewer and fewer corporations controlling such
critical sectors as information, energy, transport
and communication; this process has been de
scribed as transnationalisation. Multinational
corporations were- increasingly becoming
transnational in their operations, spreading differ
ent components of their manufacturing processes
to different countries where resources and condi
tions for their operations were optimal. Thus,
around 100 TNCs control 33% of the world’s
productive assets, account for one- third of world
production and employ only 5% of the global
workforce. At the same time, the state sector in
Third World countries, which was the only sector
large enough to enable investment for wider
development, has been pushed into a much less
significant role. Such measures as the sale of
public assets (often to TNCs), and fiscal policies
that combined decreasing taxation of the richer
segments of the population with decreasing
subsidies to weaker segments, essentially meant a
widening of income disparities. It is not surprising
that income inequalities within countries have
significantly increased.
I
poverty
CHOLERA “
T0
STARVATION
XjLkW
Reduced public sector spending to enable debt
repayment also meant that states could no longer
play a critical role in maintaining measures for
equitable development that they had in many
cases initiated. Thus the package of SAP measures
led to the collapse of the models of self-sufficient
The Political Efcrrny of the Assault cn Health
1
1
I
import-substituting industrialisation that many of
them had established in the immediate
postcolonial years. The essential feature of this
past was that socio-economic development in these
countries was based on their being exporters of
cheap primary commodities and importers of
finished manufacturedg goods.
other words, the SAP measures have been success
ful in increasing lhe rates of exploitation of the
pool by the rich. Liberalised capital markets meant
that n illions of dollars could Bow in and out of a
country within a single day. As the crises in East
Asia have indicated, the Tree flow of capital in
search of quick profits has left in its wake devas
tating poverty and social disruption. .
Many SAP-implementing countries fell from their
iriitial debt into the debt trap wherein they had to
take increasing loans merely to pay back the
interest on their earlier loans. Since they now
received less for the raw materials they exported,
they were forced to undertake repeated devalua
tion and thus paid more for imported products.
They became caught in a vicious.cycle of low
capital for initiating development, borrowing,
devaluation, and less capital. Furthermore, the net
flow of resources from the countries of the South
to those of the North substantially increased.
UNICEF, for instance, estimates that this outflow
now amounts to 60 billion dollars annually. In
As noted by the UNDP, free market expansion has
outpaced systems to protect the social well-being
of people and human development. Recent’UNDP
Human Development Reports note that more
progress has been made in norms, standards,
policies and institutions for open globaPmafkels
than for people and their rights. They note that
when economic growth through the marker is left
uncontrolled, it inevitably concentrates wealth and
power in the hands of a select group of already
powerful people, nations and corporations, while
marginalising others.
Although these neoliberal policies have
often been described as a
neocolonialization, influential sectors in
Third World countries have expressed
their support for them. 1 hese sectors,
which benefited disproportionately from
postcolonial development in the 1950s and
1960s, have given up ideas of national
self-sufficiency, independence and sover
eignty, which guided them before. They
now intent to reap the benefits as junior
partners to foreign capital in search of
quick profits, or the purchase of public
assets at a low price through privatisation,
these classes have lent open support to the
policies of the World Bank and the IMF.
Aiding this process has been the role of
the global media, which transmits mes
sages glorifying_ consumerism. Not to be
uinderplayed is the role of illicit sources of
money from trade in drugs, and rewards
to politicians in the Third World for pro
tecting these practices.
There have been two significant political ramifica
tions of this process. First, international financial
institutions and TNCs consolidated their position
through institutional measures. Under the new
world trading order, which emerged with the
completion of the Uruguay Round of talks in
Marrakech, the role of the Bretton Woods institu
tions and national governments was redefined. It
was envisaged that in the articles of the new
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International organisations
ah^iBticral elites
■W" I is equally true that several global insliiulions
I of lhe United Nations have themselves been a
1_ part of this process. The World Health Organi
zation (WHO), for instance, has increasingly
forfeited its leadership role in health to the World
Bank; indeed the total budget of the WHO is less
than the health spending of the WB. It has also
been suggested that the interests represented by
the advanced capitalist countries have themselves
increasingly influenced such institutions. Policy
prescriptions such as the endorsement of the
concept of Disability adjusted life.years (l)Al.Ys)
in health means an approach to health services
development that increases lhe role of the private
health sector and the pharmaceutical industry. The
World Trade Organization (WTO) has become a
forum ot debate and struggle over the extent to
which trade and industry, including the pharmaceutical industry, should have rights over govern
ments to meaningfully protect resources and
public health. Rapidly changing trade regulations
demand capacities and negotiating abilities that
many developing countries do not have.
The dominance of neoliberal policies across the
globe was also linked to the collapse of the social
ist economies. The ideological vacuum of alterna
tives to free-market promises at the global level
led to the demoralisation of social movements that
rejected first colonial and later neocolonial policies
of development.
Pecple's Health Asserrbly
13
World Trade Organisation (which was to have
been endorsed in Seattle), many aspects of SAP
would become legally enforceable articles in
international law. Third World countries would
thus be at an increasing disadvantage, and less
and less the owners of their own indigenous
biological materials and knowledge.
The WTO has been criticised for its lack of trans
parency and democracy in decision-making, but
the problem runs even deeper. In the profoundly
uneven playing field on which the process of
global economic change is taking place, even a
transparent WTO would not pursue the values or
principles that would enable the vast share of the
world's population to access resources or enhance
their productive capacities.
The second ramification is that national govern
ments in many Third World countries, after losing
support from the former socialist countries, failed
to build stronger South to South links with neigh
bouring countries or with those producing similar
primary commodities; instead they embarked on a
competitive race to integrate into the global
economy, thus pushing primary commodity and
labour prices lower.
When populations in Third World countries
resisted—and these sites of resistance are legion—
iheir governments used severe measures to sup
press them. Indeed, in many countries, scarce
public resources were often typically directed to
military and security expenditures. Thus, para
doxically, ‘liberal’ pro-market policies in much of
the developing world have been associated with
repressive politics.
here have been many sites of resist
ance to these policies in many parts
of the Third World. The Caracas anti-IMF ri
ots in 1989 were sparked off by a 200% Increase in
the price of bread. Unofficial reports indicate that in
January 1984 more than 1000 people were killed by
the police firing in Tunis when protesting adjustment
measures. Bread riots have also occurred in Nigeria
in 1989. In 1990 anti-SAP riots took place in Morocco.
The 1994 uprising in Chiapas. Mexico were also
sparked off by SAP measures.6
Movement for ahahYjG:
setbacks and hopes
he last decade of the 20"' century has seen
the weakening of democratic movements
and aspirations. This has occurred partly
because of the preoccupation with survival among
larger sections of the population and the weaken
ing of trade unions in the face of privatisation and
layoffs. It is also partly due to the increasing
centralisation of decision-making at national and
often international levels. Indeed decisions affect
ing large sections of the population in poor coun
tries are often made at distant capitals in the West,
with the national government mandated merely to
implement such decisions.
It is in this situation that poor people fallback on
their sectarian identities and turn on their equally
poor neighbours in ethnic and religious conflicts.
At the same time, increasing conflicts over scarce
resources at the local level are breaking out in a
number of places. In other cases a withdrawal into
the family occurrs, with women bearing the brunt
of this rise in violence.
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While these are mechanisms for coping with an
increasingly hostile world where people are
marginalised and disempowered, they do not
confront the sources of alienation and
disempowerment. A political culture of depend
ence, withdrawal or passivity, even as govern
ments have acted against the interests of their own
poor people, strengthens the same forces of au
thority.
The situation is not, however, completely bleak.
3
id
The Political Efccrcny cf the Assault cn Ffealth
There are significant positive developments that
indicate confrontation with this unacceptable
social and economic order. These are leading to
organisation for change at many levels: local,
national and international. Powerlessness is being
addressed through a range of movements that
organise in a representative and accountable
manner, giving voice to the voiceless. Those
movements that make links with others, pressuris
ing governments for participatory democracy and
to rebuild national priorities with a focus on the
needs and aspirations of the majority of the popu
lation, must inevitably confront the wider sources
of disempowerment. It is from this dimension of
social movements confronting the current global
political economy that there is hope for a more
humane and human-centred type of development
based on sustainability and equity. Within this
larger struggle must be located the struggle for
health for the people of the world.
uyana in South America is the poorest
country in the Western hemisphere. Since
1988, 80% of the government's revenues
have gone on servicing foreign debt. Through the
1980s and 1990s, malnutrition, child death rales,
unemployment and poverty rose dramatically as a
result of the implementation of the SAP package. In
1992, following the election of a new President, the
citizens of Guyana joined forces with the Bretton
Woods Reform Organisation (BWRO) to create the
first Alternative Structural Adjustment Programme,
which envisaged a comprehensive economic policy
to meet the basic needs of lhe entire population The
ASAP was based on the principle that a healthy
economy does not rely on exports for income and
imports for daily needs. The supporters of lhe ASAP
also rejected lhe IMP freeze on social sector spend
ing, and the President declared that raising the
standard of living of the majority was the first
objective.
Notes
1 George, Susan, A Fate Worse Than Debt: The World
Financial Crisis and the Poor. PIRG, New Delhi, 1990.
1 Hobsbawm, Eric, The Age ofExtremes: The Short Twenti
eth Century 1914-1991, Viking, New Delhi, 1994, p.269.
3 Ibid, p.412.
4 Hobsbawm, Eric, The Age ofExtremes: The Short Twenti
eth Century 1914-1991, Viking, New Delhi, 1994, p.269.
5 Ibid, p.412.
6 Information from Chossudovsky, Michel. The
Globalisation of Poverty and Ill Health' in Lighten the
Burden of Third World Health, Health Systems Trust.
Durban. 1999.
IO
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OuesY\ov\s\
•o:
:g:
What has happened to the lives of ordinary
people in your country or community in the
last two decades? How similar are the expe
riences of different countries? Who have been
the winners and losers?
Why is ‘free trade' a slogan primarily of the
rich and influential countries?
What has happened to the profile of health
and disease in poor communities? What has
caused these changes in health and ill-health?
What actions have ordinary people taken to
protect their rights to food, housing, jobs,
health and health care? How far have these
actions been coping mechanisms? How far
have they confronted the causes of their prob
lems collectively? What has been the response
of the state?
In what ways have countries acted together
Io improve their trade advantage in your re
gion? In what way have they competed with
each other? Which is more effective?
What do ordinary people know about the in
ternational banks, financial institutions,
world trade rules and markets that affect their
lives?
Have you ever thought of the range of prod
ucts available in a typical supermarket in the
West? How many of them emanate from the
Third World? How is it that these are avail
able to the middle class Westerner but not to
large populations within the countries they
come from?
I
Mohan Rao leaches al the ( enlre of Social Medicine and
Conimuniiy Health. School of Social Sciences, Jawaharlal
Nehrti University, New Delhi 110067. His special areas of
reseau h include the history and politics of health and fam
ily planning. Besides other publications, he is the editor of
the volume "Disinvesting in Health: The World Bank's Pre
scriptions for Health" (SAGE, New Delhi, 1999)
Pecple's Health Assembly
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EQUITY
some contributing social factors
by Nadina (^la^rvian and Maxmo ttarf
INTRODUCTION
I
he 1999 United Nations Human Develop
ment report begins: 'The real wealth of a
nation is its people. And the purpose of
development is to create an enabling environment
for people to enjoy long, healthy and creative lives.
This simple but powerful truth is too often forgot
ten in the pursuit of material and financial
wealth.’1
The current trend of globalisation has contradic
tory implications. While the last 50 years have
witnessed developments that augur betlt'i loi the
future of humanity—child death rates have fallen
by half since 1965, and a child born today can
expect to live a decade longer than a child born 20
years ago; the combined primary and secondary
school enrolment ratio in developing countries has
more than doubled—the world faces huge
amounts of deprivation and inequality. Poverty is
everywhere. Measured on the human poverty
inclex—more than a quarter of the 4.5 billion
people in developing countries still do not enjoy
some of life’s basic rights—
survival beyond the age of
40, access to knowledge and
adequate private and public
services.
The quickening pace of
globalisation has generated
enormous social tensions
that development policies
have failed to tackle. The
underlying assumption has
been that once economic
fundamentals are corrected,
social issues will resolve
themselves of their own
accord, and that well
functioning markets will not
just create wealth, but will
also resolve problems of
human welfare.2
Current events reveal with
awful clarity the depth of this fallacy. Millions of
people are poorer than ever before, with growing
indices of inequality between countries and
within countries. Most countries report erosion of
their social fabric, with social unrest, more crime,
and more violence in the home.
Neoliberal advisors in the 1980s developed a vision of the
ideal countiy: its economy would be largely self-regulating
through open competition between private firms; its public
sectorwould be relatively passive—providing the minimum
services necessary to conduct private business efficiently
and to protect society’s weakest members.
This dogmatic economic prescript ion, concludes tlie
United Nations Research Institute in Social Development
(UNRISD), has not only had limited value, but has been
dangerous. Even those countries that have been held up as
economic success stories have been social failures. Most
people in highly indebted African and Latin American
countries have suffered a sharp drop in living standards.
Between 1980 and 1990 the per capita income declined
markedly in developing countries. An International Labour
Organization study of 28 African countries showed that
the real minimum wage fell by
20% and more than half of
Africa’s people now live in
absolute poverty. In most Latin
American countries the real
minimum wage fell by 50% or
more. Coupled with this, people
have suffered from severe cuts
in public services—affecting
nutrition, health, education and
transport.
The UN Human Development
Report of 1999 goes further: a
comparison between the size of
income of the fifth of the world’s
people living in the richest
countries and that of the fifth in
the poorest showed a ratio of 74
to 1 in 1997, up from 60 to 1 in
1990 and 30 to 1 in 1960.
The advocates of adjustment
I
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Rpity and Inequity May
11
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had hoped for a trade-off: long-term economic
gain in return for short-term social cost. What they
did not foresee was that the social impact could
itself frustrate the desired economic effect. This
temporary sacrifice for the poor is beginning to
look like a permanent intensification of poverty.
UNRISD explains: ‘When the market goes too far in
dominating social and political outcomes, the opportuni
ties for and rewards ofglobalisation spread unequally and
inequitably—concentrating power and wealth in a select
group ofpeople, nations and corporations, marginalising
others. Globalisation in this era seeks to promote eco
nomic efficiency, generate growth and yield profits. But it
fails on t he goals ofequily, | poverty eradicatioi i ancI
enhanced human security. ’
Economic growth, an important input for human develop
ment, can only translate into human development ifthe
expansion of private income is equitable, and only if
growth generates public provisioning that is invested in
human development—in schools and health centres rather
than arms. Reduced public spending weakens institutions
ofredistribution—leadingto inequalities.
FACTORS^
elow are some of the major factors shaping
inequality in a globalised environment:
Institutions
Institutions matter for development. In 1997, the
World Bank warned: ‘Without adequate institu
tions, the potential benefits of globalisation in
terms of higher growth and investment rates will
either not happen, or be too concentrated, thereby
increasing, rather than decreasing inequalities and
social tensions’. It adds further that ‘good institu
tions are critical for macroeconomic stability in
today’s world of global financial integration’.3
UNRISD states: ‘Social institutions have not just
been ignored but they have been considered
obstacles to progress and have been ruthlessly
dismantled. This has happened at every level.
At national level, many state institutions have
been eroded and eliminated. And at local level,
the imperatives of market forces have been
undermining communities and families.’
The formal or semi-formal ties between states
and society are increasingly unravelling, and
being replaced by more diffuse arrangements.
States aregrowing weaker, and state institutions
are less able to fulfil basic responsibilities in
areas that encourage personal development
such as education, health, nutrition, land redis-
1
Etecple's Health Assembly
tribution and welfare.
As states weaken, power is being transferred to
institutions that ignore the social implications of
their actions, while at the same time responsibility
for absorbing the damage is being passed to non
governmental agencies or to communities and
families that have themselves been so weakened
that they are in no position to respond.
Politicalpartiesh'dve become more diffuse and frag
mented, particularly in the former Eastern Bloc countries
where institutional chaos is common.
Trade Unionsiwe. being eroded—suffering from
changes in working patterns. In countries with
high unemployment, employers are finding it
easier to avoid dealing with trade unions and are
dealing directly with individual workers.
NGOsare increasing their influence and, have been
used to deliver services in many developing
countries where governments are incapable of
providing services. Accountability is thus under
mined.
1
While many national institutions are being weak
ened, forcing communities and families to t.'jike on
added burdens, other institutions are enjoying
much greater freedom—without any commensu
rate increase in responsibility. This is especially
true for Transnational corporations (TNCs), which
now control 33% of the world’s productive assets,
but only employ directly or indirectly 5% of the
global workforce. TNCs are accused-of exploiting
cheap labour in developing countries, marketing
dangerous products, avoiding taxation and caus
ing serious environmental damage. Despite this,
they remain untouched by any form of interna
tional regulation. In cases where national govern
ments try to exert pressure on them, the companies
move elsewhere.
Education
Persistent inequality and low quality characterise
basic education systems in developing countries.
L’e.:.
Droit des
travailleur
derechos
de los
frabajadort
workers^/
rights
iwtc
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countries, employment creation has lagged
behind GDP growth and the expansion of
trade and investment. More than 35 million
people are unemployed, and another 10
million are not taken into account in the
statistics since they have given up looking
for a job. Among youth, one in five is unem
ployed.
In both poor and rich countries, dislocations
from economic and corporate restructuring
and dismantled social protection have meant
heavy job losses and worsening employment
conditions. Jobs and incomes have become
more precarious. The pressures of global
competition have led countries and employ
ers to adopt more flexible labour policies
and work arrangements with no long-term
commitment between employer and em
ployee.
I
Education inequalities in access to school, attend
ance, quality of teaching and learning outcomes—
perpetuates income and social inequalities. Poor
children attend poor schools, have less opportu
nity to complete their basic education, and per
form below their counterparts in private schools.
Misallocation of resources, inefficiencies and lack
of accountability are prominent attributes of the
organisational structure of education in most
countries. According to the report by the UNHDP,
one in seven children of primary school age is out
of school.
Corruption
Corruption seriously weakens the ability of na
tions to ensure wealth is distributed fairly. Cor
rupt officials siphon off wealth from public and
private sources, and discourage investment by
those who fear profits will be stolen.
Weak governments allow tax evasion to flourish,
undermining one of the key government tools for
wealth redistribution by denying governments
adequate resources to alleviate poverty and assist
development.
Underground or informal economies have grown,
further reducing national tax bases and feeding
criminal organisations that grow up around the
infornial economies.
Employment and unemployment
Expansion of trade does not always mean more
employment and better wages. In the OECD
Dislocation of populations
Migration is now a major global preoccupation,
although it represents nothing new. In today’s
globalising world, migration is marked by uneven
human opportunities and uneven human impacts.
Whilst global employment opportunities are
opening for some, they are closing for most others.
For high-skilled labour, the market is more inte
grated, but the market for unskilled labour is
highly restricted by national barriers.
While most migrants have some choice over when
and how to leave, millions of others become
refugees—driven from their homes and countries
by famine, drought, floods, war, civil conflict,
mass persecution, environmental degradation or
misguided development programmes.
Dislocation ofpopulations through wars and eco
nomic crises prevents stable growth in the sending
countries and leaves them dependent on uncertain
remittances from migrants. In Lesotho, 60% of
households send labourers to work in South
African mines, leaving females to cope with
managing families. People who leave are often the
youngest and most enterprising—predominantly
male—leaving communities with high proportions
of elderly people, women and young children.
An alarming outbreak of national conflicts based on
race, religion or ethnic identity has fed social
tensions and conflicts—especially when there are
extremes of inequality between the marginal and
the powerful. Inequalities are reflected in incomes,
political participation, economic assets and social
conditions—education, housing and employment.
Apart from killing or maiming millions of people,
i.
Equity and Inequity May
72
these wars weaken or destroy societies, devastate
infrastructure and the environment, and bring
public services to a standstill—undoing decades of
development.
Global crime
Crime is a growth industry that is likely to inten
sify as a result of globalisation. Modern means of
transportation, advanced communications and
relaxed border controls have created opportunities
for transnational crime. Organised crime is now
estimated to gross US$1.5 trillion a year. Illicit
trade in drugs, women, weapons and laundered
money is contributing to the violence and crime
that threaten neighbourhoods around the world.
A high proportion of modern-day criminal activity
is associated with narcotic drugs. Illicit drugs have
a corrosive effect in both consuming and produc
ing countries. Drug syndicates, gangs and smug
glers use any means necessary to protect their
trade—whether it be murder, or bribery and
corruption—undermining institutions and social
systems such as traditional agricultural communi
ties. The illegal drug trade in 1995 was estimated
at about 8% of world trade.
All these factors have a direct effect on families,
but especially on women and children. Around the
world one in every three women has experienced
violence in an intimate relationships, and about 1.2
million women and girls under 18 are trafficked
for prostitution each year. About 300 000 children
were soldiers in the 1990s, and 6 million were
injured in armed conflicts'’.
Farnilies and women
Ihe weakening offamilies. The family has always
offered the most basic form of security. When all
else fails, people have assumed that they can rely
on their family members for support. This has
become especially important during the current
era of economic restructuring that has seriously
weakened the capacity of the state to provide for
those in greatest need. Unfortunately, this is
happening at a time when the family itself is
coming under the greatest pressure it has known.
In industrialised countries, around one third of
marriages end in divorce, and 20% of children are
born outside marriage. Many of the current social
ills are blamed on the family—from high crime to
teenage pregnancies, to drug taking.
One of the most widely discussed changes in the
structure of the family is the rising proportion of
single-parent families— generally women. Female
headed households are disadvantaged, not be-
Pscple's Health Assembly
cause women lacking a sense of responsibility
towards their families, but rather because social
and economic factors are stacked against them—
women face discrimination in property, land,
income and credit. Social and economic changes in
recent years have made family life even harder for
women. Many more women are working outside
the home—in industrial countries women make up
40% of the official labour force. The economic
crisis in many countries has increased women’s
workload in other ways. It has been found that
women suffer more from cuts in public services—
health cuts mean that women take care of sick
relatives, and cuts in education mean that women
spend more time supervising children, which
UNRISD calls ‘invisible adjustment’. Further,
women spend more time growing their own
food—and this has been transferred to their
daughters at the expense of attending school.
A current problem, which is reaching unprec
edented proportions, is the number of orphans as a
result of the AIDS epidemic. Since the beginning
of the epidemic there have been 13.2 million
orphan in the world, most of them are in SubSaharan Africa. These children are taken care by
their extended families or emerging institutions
that have not only to ensure their survival but
address the psychological, health and social needs. This
increasing problem can only be expected to get worse in
the future.
1
Children
The same pressures that hove taken their toll of
parents have also taken their toll of children. In the
industrialised countries, the period 1950-1975 saw
remarkable progress for children—whether
measured by health, growth rates or education.
These rates of progress are being brought to a halt.
There is a steady rise in school drop-out rates,
more cases of physical and sexual abuse, and rises
in teenage violence and suicide. Children in
J
yv'gnrr. newsletter 62
developing countries come under even greater
pressure. Whilst child survival rates have im
proved enormously over the last 30 years—infant
and under-five mortality rates more than halved—
those who survive live under greater stress.
I
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In developing countries there are some 250 million
child labourers -140 million are boys and 110
million girls4. Pqverty and low wages are the
underlying reasons for child labour, parents earn so
little that their children have to work and employ
ers are happy to take children as they will work
for ev'en lower wages, (children’s wages may pay
for their own schooling as well as keep the family
together as a unit)
THE
f UTURE
A a J e face the challenge of setting up rules
1 /\ r and institutions for stronger govern
V V ance—local, national, regional and
global—that put the health and well-being of each
individual, community and nation at the centre.
We need to create enough space for human,
community and environmental resources to ensure
that development works for people and notjust for profit.
Globalisation expands the opportunities for
unprecedented human advance for some, but
shrinks those opportunities for others and erodes
human security. It is integrating economies,
culture and governance, but is fragmenting socie
ties and ignoring the goals of equity, poverty
eradication and human development.
1
Questions'?
What are the social factors that influence
the health situation in your community or
countries?
Is violence a problem in your community?
What is the status of Women and children?
Is government responding to the people’s
needs? Why?
Notes
1 UNDP. -^United Nations Human Development
Report-1. 1999. Geneva.
1 United Nations Research Institute in Social Develop
ment. -IStates of disarray. The social effects of
globalizationl. 1995. Geneva.
3 Report Institutions Matter - World Bank Latin Ameri
can and Caribbean studies 1998
4 UNDP. “Human Development Report 2000. New
York, USA.
Nadine Gasman is a physician and Doctor in Public health
from Mexico. She has worked as a consultant for different
government and non-governmental organizations especially
in the area ofhealth andpharmaceuticalpolicies. She is the
coordinator ofthe analytical drafting group ofthe PHA.
Maxine Hart is a social worker from South Africa with
experience in human development policies. She worked as a
consultant in human development policies and restructuring
oforganisation after apartheid was abolished in South Africa.
Overcoming poverty must be seen as the main
ethical and political challenge. Experience shows
that the most appropriate programmes are long
term initiatives of a comprehensive/ multi-dimen
sional and multi-sectoral nature, aimed at break
ing down the mechanisms that perpetuate poverty
from one generation to another.
Development patterns need to be oriented to make
equity—that is, the reduction of social inequality—
the central pillar. This should be the basic yard
stick against which we measure development.
Education
employment present two master
keys for development. Education has an impact on
equity, development and citizenship, and there
fore needs to be assigned top priority in terms of
social policy and public spending, especially
important is education of girls. Latin American
studies have indicated that 11-12 years of school
ing (completed secondary education) are required
if people are to have a chance of escaping poverty.
At the same time, a high-quality job- creation
process needs to be put in place.
Hguity and Ineqaity May
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communacafjon
odoptmq heolth promotion ond sociol oction to the
qlobo' '.mbolonced of the 21st centurq
by Pad J Wezrn&r
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death for millions. Increasingly, giant banks and
corporations rule the world, putting the future
well-being and even survival of humanity at risk.
Driven more by hunger for private profit than for
public good—the massive production of consumer
goods far exceeds the basic needs of a healthy and
sustainable society. Indeed, its unregulated
growth compromises ecological balances and
imperils the capacity of the planet for renewal.
Democracy^, a
prerequisite
for a HEALTHY
SOCIETY
Why participation is essential - and how it
is undermined
I
he well-being of an individual or commu
nitv depends on many factors, loi al to
global. Above all. it depends on the oppor
tunity of all people to participate as equals in the
decisions that determine their well-being Unfor
tunately. history shows us that equality in collec
tive decision-making—that is to say participatory
democracy—is hard to achieve and sustain.
Despiije the spawning of so-called ‘demot lallc
governments’ in recent
decades, most people
still have little voice in
the policies and deci
sions that.shape their
lives. Increasingly, the
I
rules governing the
fate of the Earth and its
inhabitants are made
by a powerful minority
who dictates the Global
Economy. Thus eco
nomic growth (for the
wealthy) has become
the yardstick of social
progress, or ‘develop
ment,’ regardless of
the human and envi
ronmental costs
Yet in a world where unlimited production and
resultant waste have become a major health
hazard, there are more hungry children than ever
before. According to Worldwatch's The State ofthe
World, 1999, the majority of humanity is now
malnourished, half from eating too little and half
from eating too much!
And the costs are horrendous! The lop down
‘globalisation’ of policies and trade-- through
which the select few profit enormously at the
expense of the many—is creating a widening gap
in wealth, health and quality of life, both between
countries and within them. A.complex of world
wide crises social, economic, ecological and
ethical—is contributing to ill-health and early
Mahatma Gandhi wisely observed: ‘There is
enough for everyone's need but not for everyone’s
greed Sadly, greed has replaced need as the
driver of our global
spaceship. Despite all
the spiritual guidelines,
social philosophies,
and declarations of .
human rights that
Homo sapiens (the
species that calls itself
wise) has evolved
through the ages, the
profiteering ethos of
the market system has
side-tracked our ideals
of compassion and
social justice. Human
ity is running a danger
ous course of increas
ing imbalance. To
further fill the coffers of the rich, our neoliberal
social agenda systematically neglects the basic
needs of the disadvantaged and is rapidly despoil
ing the planet’s ecosystems, which sustain the
intricate web of life.
The dangers—although played down by the mass
media—are colossal and well documented. For
ward-looking ecologists, biologist, and sociologists
sound the warning that our current unjust, un-
Ctnnunicaticn a«3 if Ffecple Mattered
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healthy model of economic development is both
humanly and environmentally unsustainable.
‘Yes, we know that,’ say many of us who believe
in Health for All and a sustainable future. ‘We are
deeply worried.... But what can we do?
There are no easy answers. The forces shaping
global events are gigantic, and those who accept
them as inevitable so impervious to rational
dissent, that many of us hide oui heads in the sand
like ostriches. And so humanity thunders head
long down the path of systemic breakdown—more
polarisation of society, more environmental
deterioration, more neglect of human rights and
needs, more social unrest and violence—as if our
leaders were incapable of thought and our
populations anaesthetised.
What action can we lalw. then—individually and
collectively—to change things for the better, for
the common good?
The purpose of this background paper
The interrelated crises of our times—the ways that
globalisation, corporate rule, and top-down,
‘development’ policies undermine democratic
process and endanger world health—are discussed
in other background papers for the People’s
Health Assembly. The purposes of this paper are:
to examine the strategies used by the world’s
ruling class to keep the majority of humanity
disempowered and complacent in the face of
the crushing inequalities and hazards it
engenders;
2. to explore the mellmds and resources whereby
enough people can liri ome sufficiently aware
and empowered to « ollectively transloim oui
current unfair social order into one that is
more equitable, compassionate, health-pro
moting. and sustainable.
1
TOP
"Do
MLA5UR.E.S of
SOCIAL CONTROL
Disinformation
A
|iib all the technology and sophisticated
1 /\ /means of communication now available.
V V how is it that so many people appear so
unaware thal powerful interest groups are under
mining democracy, concentrating powei and
wealth, and exploiting both people and the envt,.,nniii'Ul >n ways that put the well-being and even
survival of humanity at stake? How can a small
elite minnril'. so successfully manipulate global
poliiks in its own advantage, and so callously
ignore the enormous human and environmental
costs7 How can the engineers of the global
economy so effectively dismiss the emerging risk
of unprecedented social and ecological disastei.
In short, what are the weapons used by the ruling
class to achieve compliance, submission, and social
control of their captive populat ion?
True, riot squads have been increased, prison
populations expanded, and military troops de
ployed to quell civil disobedience. But far more
than tear-gas and rubber bullets, disinformation
has become the modern means of social control
Thanks to the systematic filtering of news by the
mass media, many ‘educated’ people have litde
knowledge >1 Hie injustices done to disadvantaged
people in the name of economic growth, or of the
resulianl penis facing humanity. They are uncon
scious of the f.icl that the overarching problems
affecting their well-being-growing unemploy
ment reduced public services, environmental
degradation, renewed diseases of poverty, bigger
budgets for w eapons than for health caie or
schools, more tax dollars spent to subsidize
wealthy corporations than to assist hungiy chil
dren. rising rates of crime, violence, substance
abuse, homelessness, more suicides among teenagers—are rooted in the undemocratic concentration
of wealth and power. Despite their personal
hardships, unpaid bills, and falling wages, ordi
nary citizens are schooled to rejoice in the success
ful economy’ (and spen'd more). They pledge
allegiance to their masters’ Hag. praise God lor
living in a Tree world,’ and fail to see (or to admit)
the extent t<> which the world s oligarchy (ruling
minority) is undermining democracy and endan
gering our common future. And our textbooks and
TVs keep us urategically misinformed.
J
People's Health Assentoly
One dollar, one vote: private invest
SEAD AGAIN - Wf TH
FEELING -THE PASSAGE
ment in public elections
One way government by the people’ is
undermined is through the purchase of
public elections by the highest bidders. In
many io-called democracies a growing
1
i
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I
^ABour the reroesof
REVOLUTION .
number of citizens (in some countries, the
majority) don’t even bother to vole. They
v
say it makes no difference. Polilician.s un<
elected, pay little heed to the people s
wishes. The reason is that wealthy interest
groups haj<ze such a powerful political
lobby. Their big campaign donations (bribes?)
help politicians win votes—in exchange for politi
cal favours. The bigger the bribe, the more cam
paign propaganda on TV and mass media. Hence
more votes.
reforms, institutionalised disinformation must be
exposed for what it is. To accomplish this, more
honest and empowering forms of education and
information sharing are needed.
Schooling for conformity, not change
This institution of legal bribery makes it hard for
honest candidates (who put human need before
corporate greed) to get elected. Democratic elec
tions are based on one person, one vote. With the
deep pockets of big business corrupting elections,
results are hast'd on one dollar, one vole. This
makes a mockery of the democratic process.
It has been said that education is power. That is
why, in societies with a wide gap between the
haves and have-nots, too much education can be
dangerous. Therefore, in such societies, schooling
provides less education than indoctrination,
training in obedience, and cultivation of conform
ity In general, the more stratified the society, the
more authoritarian the schools.
The erosion of participatory democi at v by die
corporate lobby has far-reaching human and
environmental costs. Hence the biggest problems
facing humanity today—poverty, growing in
equality, and the unsustainable plundering of the
planet‘s ecosystems—continue unresolved
Sufficient wisdom, scientific knowledge and
resources exist to overcome poverty, inequily,
hunger, global warming and the other crises facing
our planet today. But those with the necessary
wisdom and compassion seldom govern. They
rarely get elected because they refuse to sell their
souls to the company store. Winners of elections
lend to be wheelers and dealers who place short
term gains before the long-term well being of all.
To correct this unhealthy situation, laws need to be
passed that stop lobbying by corporations and
wealthy interest groups. In some countries, citi
zens’ organisations are working hard to pass such
campaign reforms. But it is hard to g<i them past
legislators who pad their pockets with i oi pot ale
donations. Only when enough citizens become
fully aware of the issues at stake and demand a
public vol'1 to outlaw large campaign donations,
will it be possible for them to elect officials who
place the common good before the interests of
powerful minorities.
But creating such public awareness is an uphill
struggle—precisely because of the power of the
corporate lobby and the deceptive messages of the
mass media. To make headway with campaign
7
Government schools tend to teach history and
civics in ways that glorify the wars and tyrannies
of those in power, whitewash institutionalised
transgressions, justify unfair laws, and protect the
property and possessions of the ruling class. Such
history is taught as gospel. And woe be to the
conscientious teacher who shares with students
people’s history’ of their corner of the earth.
Conventional schooling is a vehicle of
disinformation and social control. It dictates the
same top-down interpretations of history and
current events, as do the mass media. It white
washes official crimes and aggression. Its purpose
is lo instill conformity and compliance, what
Noam Chomsky calls ’manufacturing consent.’
For example, although the United States has a long
history of land-grabbing, neocolonial aggression
and covert warfare againsl governments commit
ted to equity, most US citizens take pride in their
benevolent, peace-loving nation’. Many believe
they live in a democracy ‘for the people and by the
people, with liberty and justice for all’—even
though millions of children in the US go hungry,
countless poor folks lack health care, prison
populations expand (mainly with destitute blacks),
and welfare cut-backs leave multitudes jobless,
homeless and destitute.
Ctmnjiucaticn as if Ffecple Mattered
83
-41
the controlling elite. But to survive they need
the- NHW f0^
M-UP approaches
oT m to communication
o see through the institutionalised
disinformation, and to mobilise people
in the quest for a healthier, more equita
ble society, we need alternative methods of
education and information sharing that are
honest, participatory, and empowering. This
includes learning environments that bring people
together as equals to critically analyse their reality,
plan a strategy for change, and take effective
united action.
listener support.
Internet. Electronic mail and websites have
opened up a whole new sphere of rapid, direct
communication across borders and frontiers. The
Web is. of course, a two-edged sword. The Internet
Is currently available to less than 2% of the world s
people, mostly the more privileged. And instant
elecimnii communications facilitate the global
Iran .actions and control linkages of the i tiling
Hass But at Hie same time. E-mail and the WorldWide Web pi ovide a powerful tool for popular
organisations and activists around the globe to
communicate directly, to rally for a common cause
and to organise international solidarity for action.
Fostering empowering learning methods is urgent
in today’s shrinking world, where people’s quality
of life, even in remote communities, is increasingly
dictated by global policies beyond their control.
Alternative media and other means of
people-to-people communication
There have been a number of important initiatives
in the field of alternative media, communication,
and social action for change.
The alternative press. While struggling to stay
alive in recent years, the alternative press (maga
zines. flyers, bulletins, newsletters, progressive
comic books) has provided a more honest, peoplecentred perspective on local, national and global
events. Some of the more widely-circulating
alternative magazines in English (often with
translations into several other languages) include
The New Internationalist
Z Magazine
Resurgence
The Nation
Third World Resurgence
Covert Action Quarterly
Multinational Monitor
Also, there are many newsletters and periodicals
published by different watchdog groups such as
the International Forum on Globalization. IBFAN.
BankWatch, the National Defense Monitor and
Health Action Internalimial. among cithers. It is
important that we subscribe to and read (and
encourage others to read) these progressive alter
native writings.
Alternative community radio and TV. The role
and potential of these is similar to that of the
alternative press. Stations that do not accept
advertising are less likely to belong to or sell out to
I
Rxple's Health Assentoly
The potential of such international action was first
demonstrated by the monumental worldwide
outcry, through which non-government organisa
tions (NGOs) and grassroots organisations halted
the passage of the Multilateral Agreement on
Investment (MAI). (The MAI was to have been a
secret treaty among industrialised countl ies,
giving even more power and control ovei Third
World Nations.) The primary vehicle of communi
cation for the protest against MAI was through the
Internet.
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Mass gatherings for organised resistance against
globalised abuse of power. The turn of thp Cen
tury was alsn a turning point in terms of people’s
united resistance against global trade policies
harmful to people and the planet. The huge, \yellorchestrated protest of the World Trade Organiza
tion (WTO) summit meeting in Seattle. Washing
ton (now celebrated worldwide as the ‘Battle-in
Seattle') was indeed a breakthrough. It showed us
that when enough socially committed people
from diverse fields unite around a common
concern, they can have an impact on global
policy making
The agenda of the WTO summit in Seat He was to
further impose its pro-business, anti-people and
anti-environment trade policies. That agenda was
derailed by one of the largest, most diveise,
international protests in human history Hundreds
of groups and tens of thousands of people repre
senting NGOs. environmental organisations,
hum m lights groups, labour unions, women’s
organtsallon-.. and many others joined to protest
and barricade the WTO assembly. Activists ar
rived from at least 60 countries. The presence of
so-many grassroots protesters gave courage to
many of the representatives of Third World
countries to oppose the WTO proposals which
would further favor affluent countries and corpo
rations at the expense of the less privileged. In the
end. the assembly fell apart, in part from internal
I
disaccord. No additional policies were agreed
upon.
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The People s Health Assembly, with its proposed
People's Charter for Health' and plans for follow
up action, holds promise of being another signifi
cant step forward in the struggle for a healthier,
more equitable approach to trade, social develop
ment. and participatory democracy. For that
promise to be realised, people and groups from a
wide diversity of concerns and sectors must
become actively involved around our common
concern: the health and well-being of all people
and of the planet we live on.
for
PAIVnC NATION,
f
EMfWERMENT, and
ACTION for change
he term ‘Popular Education,' or ‘Learnercentered education.' refers to participatory
learning that enables people to take collec
tive action for change Many community-based
health initiatives have made use of these enabling
methodologies, adapting them to the local circum
stances and customs. Particularly in Latin
America, methods of popular education have been
strongly influenced by the writings and aware
ness-raising 'praxis' of Paulo Freire (^ hose best
known book is
(he Oppress'd}
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Education of the oppressed—the method
ology of Paulo Freire
In the mid-1960s the Brazilian educator. Paulo
Freire developed what he called education for
liberation, an approach to adult literacy training,
(which proved so revolutionary that l-reire was
jailed and.then exiled by the military junta ) With
his methods, non-literate workers and peasants
learned m’read and write in record time—because
their learning focused on what concerned them
most: the problems, hopes and frustrations in their
lives. Together they critically examined these
concerns, which were expressed in key words and
provocative pictures The process involved identi-
IS TOO TWIN-
Wliy ’ J
f SHE DOESN’T SET ENOUGH TO EAT.
THAT'S A 6000 ANSWER . WHO HAS
Perhaps the most important outcome ol the Battle
in Seattle was that, despite efforts by the mass
media to denigrate and dismiss the protest, key
issues facing the world's people were for once
given center stage. It was a watershed event in
terms of grassroots mobilisation for change. But
the activists present agreed that it was just a
beginning
EDUCATION
I
f INDIRA
HER PARENTS
ANOTHER. ONE’WHT DOESN'T INDIRA
ARE IN
DEBT.
HE-R FATHER
IS SICK.
her
mother
DOESN'T
.
BREAETFEE.D
HER.
fication and analysis of their most oppressive
problems, reflection on the causes of these, and
(when feasible) taking action to ‘change their
world'.
Learning as a two-way or many-way
process
With Freire’s methodology, problem-solving
becomes an open-ended, collective process. Ques
tions are asked to which no one, including the
facilitator have ready answers. ‘The teacher is
learner and the learners, teachers.' Everyone is
equal and all learn from each other. The contrast
with the typical classroom learning is striking.
In typical schooling, the teacher is a superior
being who 'knows it all’. He is the owner and
provider of knowledge. He passes down his
knowledge into the heads of his unquestioning
and receptive pupils, as if they were empty pots.
(Freire calls this the 'banking' approach to learning
because knowledge is simply deposited.)
In education for change, the facilitator is one of
the learning group, an equal. She helps partici
pants analyse and build on their own experiences
and observations. She respects their lives and
ideas, and encourages them to respect and value
one another’s. She helps them reflect on their
shared problems and the causes of these, to gain
confidence in their own abilities and achieve
ments. and to discuss their common concerns
critically and constructively, in a way that may
lead to personal or collective action. Thus, accord
ing to Freire, the learners discover their ability to
change their world'. (For this reason Freire calls
this a 'liberating' approach to learning).
Ctinrunicaticn as if Dscple Mattered
that the poor often went without. Heallli workeis
The key difference between ‘typical schooling and
•education for change’ is that the one pushes ideas
into the student’s heads, while the other draws
ideas from them. Typical schooling, trains students
to conform, comply, and accept the voice <if
authority without question. Its objective is to
maintain and enforce the status quo. It is
disempowering. By contrast, education-for-change
is enabling. It helps learners gain ‘critical aware
ness* by analysing their own observations, draw
ing their own conclusions and taking collective
action to overcome problems. It frees the poor and
oppressed from the idea that they are helpless and
must suffer in silence. It empowers them to build a
better world—hence it is ‘education for transfor
mation’.
examples of
graswots
health programmes
tha'f have ccrrtetted
ROOT CAUSES of
POOR. HEALTH
ommunity-based health programmes in
f
various countries have brought people
V_ ^x^tngether to analyse the root causes of theii
health-related problems and to ‘take health into
their own hands' through organised action. In
places where unjust government policies have
worsened the health situation, community health
programmes have joined with popular struggles
for fairer and more representative governments.
The following are a few examples of programmes
where people’s collective ‘struggle for health has
led to organised action to correct inequalities,
unfair practices and/or unjust social structures.
Gonoshasthaya Kendra (GK). GK is a comma
nity health and development programme In
Bangladesh that began during the war for
national independence. Village women, many
of them single mothers (the most marginalised
of all people), have become community health
workers and agents of change. Villagers collec
tively analyse their needs and build on the
knowledge and skills they already have. Re
peatedly health workers have helped villagers
take action to defend their rights.
One example of this is over water rights. In
analysing their needs, families agreed that
access to good water is central to good health.
UNICEF had provided key villages with tube
wells. But rich landholders took control of the
wells and made people pay so much for water
People's Health AsE’«:ntoly
helped village is organise to gain democratic.
nnHmunity < omrol of the wells. This meant more
wan r and belter health for the poor. And it helped
people gain < onfidence that \hrough organised
I
I
action they could indeed better their situation.
Another example concerns schooling. Villagers
know education is important for health. But most
poor children of school age must work io help
their families survive. So (he GK communities >
started a unique school, which stresses coopera
tion not competition. Each day the children able to
attend the school practise teaching each other. .
After school these same children teach those
unable to attend school. This process of teaching
one another and working together to meet their
common needs, sews seeds for cooperative action
1
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for change.
Jamkhed, India. For over three decades two
doctors. Mabel and Raj Arole. have worked with
pooi village women, including traditional mid
wiv. s These health facilitators have learned a
wide vat lety of skills. They bring groups of
women together to discuss and try to resolve
problems. In this way. they have become informal
community leaders and agents of change They
help people rediscover the value of traditional
forms of healing, while at the same time demysti
fying Western medicine, which they learn to use
carefully in a limited way.
In Jamkhed. women's place relative to men s has
become stronger. Women have found coinage to
defend their own rights and health and those of
their children. As a result of the empowerment
and skills-training of women, child mortality has
dropped and the overall health of Hie community
has improved dramatically.
TO PAY 1
M'
SOCIAL
WHY
DRAMA :
DO
FARM PEOPLE LEAVE
AW MO
to cm
SLU^S^
r
rW
- ?v- •■•
111Ms
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The Philippines. In this island nation, during the
dictatorship of Fernando Marcus, a network of
community-based health programmes (CBHPs)
evolved to help people deal with extreme poverty
and deplorable health conditions. Village health
workers learned to involve people in what they
called situational analysis. Neighbours would
come together to prioritise the main problems
affecting their health, identify root causes and
work collectively towards solutions.
In these sessions it became clear that inequality—
and the power structures that perpetuate it—
were at the root of ill health Contributing to the
dismal health situation were: unequal distribution
of farm land (with huge land-holdings by
transnational fruit companies), cut backs in public
services, privatisation of the health system, and
miserable wages paid to factory and lai m workers.
The network of community-based programs urged
authorities to improve this unjust situation. When
their requests fell on deaf ears, they organised a
popular demand for healthier social structures.
These included free health services, fairer wages,
redistribution of the land to the peasantry, and
above all else, greater accountability by the gov
ernment to its people.
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fhe lad that the CB1 IP network was awakening
people to (he socio-political causes ol the poor so
threatened the dictatorship that scores of health
workers were jailed or killed. But as oppression
grew, so did the movement. The CBHP network
joined with other movements for social change.
Finally, the long proctsss of awareness raising and
cooperative action paid off. In the massive peace
ful uprising of 1986. thousands ol citizens con
fronted the soldiers, putting flowers into (he
muzzles of their guns. The soldiers (many of
whom were peasants themselves, acquiesced.
After years of organising and grassroots resistance,
the dictatorship was overthrown. (Unfortunately,
the overall situation has not changed greatly. With
persistent domination by the US government and
multinational corporal ions, gross inequities
remain and the health of the majority is still
dismal. The struggle for a healthier, more equita
ble society continues.)
Nicaragua. Similar to the
CBHP in the Philippines
under Marcus, in Nicaragua
during the Somoza dii lalorship a network of non govern
ment community health
programmes evolved to fill
the absence of health and
other public services. Grass
roots health workers known .
as Brigadlstas de Salud
brought groups of people together to conduct
community diagnoses of problems affecting their
health, and to work together toward solutions. As
in the Philippines, the ruling class considered such
community participation subversive. Scores of
health workers were ‘disappeared’ by the National
Guard and paramilitary death squads. Many
health workers went underground and eventually
helped form the medical arm of the Frente
Sandinista, the revolutionary force that toppled the
dictatorship.
After the overthrow of Somoza, hundreds of
Brigadistas joined the new health ministry. With
their commitment to strong participation, they
helped to organise and conduct national ‘Jornadas
de Salud’ (Health Days). Their work included
country-wide vaccination, malaria control, and
tuberculosis control campaigns. At the same time,
adult literacy programmes, taught mainly by
school children, drastically increased the nation’s
level of literacy.
As a result of this participatory approach, health
statistics greatly improved under the Sandinista
government. Since the Sandinistas were ousted
with the help of the US government, health serv
ices have deteriorated and poverty has increased.
Many health indicators have suffered. But fortu
nately, communit ies still have the skills and selfdetermination necessary to meet basic health
needs and assist one another in hard times.
Project Piaxtla, in rural Mexico. In the mountains
of western Mexico in the mid-1960s a villager-run
health programme began and gradually grew to
cover a remote area unserved by the health sys
tem. Village health promoters, learning in part by
trial and error, developed dynamic teaching
methods to help people identify their health needs
and work together to overcome them.
Over the years. Piaxtla evolved through three
phases: 1) curative care. 2) preventive measures,
and 3) socio-political action.
It was the third phase that led to the most impres
sive improvements in health. (In two decades,
child mortality dropped by 80%.) Through Com
munity Diagnosis, villagers recognised that a big
‘Fl
7*2
> <* **$$££
(Ifivid werner
CbrniLn'Dcaticn as if Fecple Mattered
J
1
87
cause of hunger and poor health was the unconsli
tutional possession of huge tracts of farmland by a
few powerful landholders, for whom landless
peasants worked for slave wages. The health
promoters helped the villagers organise, invade
the illegally large holdings, and demand their
constitutional rights. Confrontations resulted, with
occasional violence or police intervention. But
eventually the big landholders and their governmenfgoons gave in. In two decades, poor farmers
reclaimed and distributed 55% of good riverside
land to landless farmers. Local people agree that
their struggle for fairer distribution of land was
the most important factor in lowering child mor
tality. And as elsewhere, people's organised effort
to improve their situation helped them gain the
self-determination and skills to confront other
obstacles to health.
The practical experience of Project Piaxtla and its
sister programme, PROJIMO, gave birth to Where
There Is No Doctor,’ ‘Helping Health Workers
Learn,’ ’Disabled Village Children' and the other
books by David Werner that have contributed to
community-based health and rehabilitation initia
tives worldwide.
nefworfeing and
COMMON
country or region began to form nctwoiks or
associations Io assist and learn from eat It other. By
joining forces they were able to form a stronger,
more united movement, especially when confront
ing causes of poor health rooted in institutional
ised injustice and inequity. »
National networks in Central America and the
Philippines provided strength in numbers ‘jhat
gave community health programmes 'mutual
protection and a stronger hand to overcome
obstacles.
>
hi the 1970s. (ommunity-based health pro
grammes in several Central Amerit an c ounli ies
Ibrmed nationwide associations. 1 hen in 1982'an
impoilanl step Ibiward look place. Village health
wotlu is Iroiii CBHPs in the various Central
American countries and Mexico met in Guatemala
to form what became the Regional Committee of
Community Health Promotion.
This Regional Committee has helped to build
solidarity for the health and rights of people
throughout Central America. Solidarity was
particularly important during the wars of libera
tion waged in Central America (and later in
Mexico), when villages were subjected to brutal
and indiscriminate attacks by repressive govern
ments and death squads.
Learning from and helping each other
arvio^
programmes and movements
One of I he niosl positive aspects of networking
among giassrouts programmes and movements
has liren the cross fertilisation of experiences,
From isolation to united struggle
mellii i Is in< I ideas.
Tn different but parallel ways, each of the com
Imunity initiatives briefly described above
ideveloped enabling participatory methods to
help local people learn about their needs, gain self
confidence, and work together to improve their
well-being. Each forged its own approaches to
what we referred to earlier as education for
change.
Central America. For example, in the 1970s. the
Regional Committee and Project PiaXtla organised
a series of ‘intercambios educativos’ or educa
tional interchanges Community health workers
from different programmes and countries came
together to learn about each other s methods ul
confidence-building, community diagnosis, and
organisation for community action.
At first community health initiatives in different
countries tended to work in isolation, often una
ware of each other’s existence. There was little
communication and sometimes antagonism
between them. But in time this changed, partly
due to growing obstacles to health imposed by the
ruling class. (Nothing solidifies friendship like a
common oppressor.) Programmes in the same
At one of these Intercambios. representatives from
Guatemala, in a highly participatory manner,
introduced methods of ‘conscientizacion’ (aware
ness-raising) developed by Paulo Freire. as they
had adapted them to mobilise people around
health-related needs in Guatemala.
<4
XiS
Appropriate planning
Efecple's Health Assentoly
starts with
PEOPLE.
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Likeu ise the village health promoters of
Piaxtla, in Mexico, introduced to participants a
varietv of methods of discovery-based learn
ing. which they had developed over the years
(see below).
Reaching across the Pacific. An early step
towards more global networking took place in
19??. when an educational interchange was
arranged between communitv health workers
from Central America and the Philippines A
team of health workers from Nicaragua.
1 loot I liras and Mexit o visited a \a ide ! ange of
community-based health programmess, rural
and urban, in the Philippines. In spite of
language barriers, the sharing of perspectives and
sense of solidarity that resulted were profound.
Social and political causes of ill health in the two
regions were similar. Both the Philippines and
Latin America have a history of invasion and
subjugation, first by Spain and then by the United
States. Transnational corporations and the Interna
tional Financial Institutions have contributed to
polarising the rich and poor. And in both regions,
the US has backed tyrannical puppet governments
that obey the wishes of the global marketeers in
exc hange lor loans and weapons to Iwp their
impoverished populations under control.
Participants in the Latin American-Pliilippine
interchange came away with a new understanding
of the global forces behind poor health. They
became acutely aware of the need for a worldwide
coalition of grassroots groups and movements to
gain the collective strength needed to construct a
healthier, more equitable, more sustainable global
environment.
life and death of
P RIMARY
RIMARY HEALTH Care
*
.1
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a ealth for All? The United Nations estab
I lished the World Health Organization
| (WHO) in 1945 to co-ordinate interna
tional policies and actions for health. WHO de
fined health as 'complete physical, mental, and
social well-being, and not merely the absence of
disease.’
But in spile of WHO and the United Nations'
declaration of Health as a Human Right, (he
poorer half of humanity continued to suffer the
diseases of poverty, with little access to basic
health services. In 1987. WHO and UNICEF
organised a watershed global conference in Alma
Ata, USSR. It was officially recognised that the
Western Medical Model, with its cosily doctors in
giant disease palaces.' had failed to reach impov
t J?
-<)
erished populations. So the world’s nations en
dorsed the Alma Ata Declaration, which outlined
a revolutionary strategy called Primary Health
Care (PHC), to reach the goal of Health for All by
the Year 2000. The vision of PHC was modeled
after the successful grassroots community-based
health programmes in various countries, as well as
the work of 'barefoot doctors' in China. It called
for strong community participation in all phases,
from planning and implementation to evaluation.
Health for No One? We have entered the 21st
century and are still a long way away from ‘Health
for All.' If our current global pattern of short
sighted exploitation of people and environment
continue, we will soon be well on the road to
Health for No One.’ The current paradigm of
economic development, rather than eliminating
poverty, has so polarised society that combined
social and ecological deterioration endangers the
well-being of all. But sustainable well-being is of
secondary concern to the dictators of the global
economy, whose all-consuming objective is
G ROWTH AT ALL COST!
It has been said that Primary Health Care failed.
But in truth, it has never been seriously tried.
Because it called for and the full participation of
the underprivileged along with an equitable
economic order, the ruling class considered it
subversive. Even UNICEF—buckling under to
accusations by its biggest founder (the US govern
ment) that it was becoming 'too political —en
dorsed a disembowelled version of PHA called
Selective Primary Health Care. Selective PHC has
less to do with a healthier, more equitable social
order than with preserving the status quo of exist
ing wealth and power.
The World Bank’s take-over of health planning.
The kiss of death to comprehensive PHC came in
1993 when the World Bank published its World
Development Report, titled ‘Investing in Health.'
The Bank advocates a restructuring of health
systems in line with its neo-liberal free-market
ideology. It recommends a combination of privati
sation. cost-recovery schemes and other measures
that tend to place health care out of reach of the
Ctmnnicaticn as if Efecple Mattered
I
poor. To push its new policies down the throat ol
poor indebted countries, it requires acceptance oi
unhealthy policies as a pre-condition to the grant
ing of bail-out loans.
In the last decade of the 20th century, the World
Bank took over WHO s role as world leadei in
health policy planning, 'fhe take-over was pow
ered by money. The Woi Id Bank s budget foi
Health’ is now triple thai of WHO s total budget
With the World Bank's invasion of health care,
comprehensive PHC has effectively been shelved.
Health care is no longer a human right. You pay
for what you get. If you are too poor, hungry and
sick to pay. forget it. The bottom line is business as
usual. Survival of the greediest!
vision is lo advance towards a healthy global
community founded on fairer, more equitable
social structures. It strives towards a model of
people-centred development, which is participa
tory. sustainable, and makes sure that all people s
basic needs are met
I
I hr IP! K is ml just a South- South network lor
uneb i de\ eloped < ountries. hut also includes
grass.uoi, snuggles for health and rights among
the growing numbers of poor and disadvantaged
people in the Northern ‘overdeveloped’ countries.
For (he last (wo years the Third World Network
and the IPHC have worked t losely together in the
preparations for the People’s Health Assembly
f
‘f
Ci?ALlTll?NS for -the-
what
DO you S£E HERE.?
tsaLth and vell-Leir^
of HUMANITY
—^-imary Heath Care as envisioned at Alma
I ^<Ata was never given a fair chance,—and
|
globalisation is creating an increasingly
polarised, unhealthy and unsustainable world. —
In response, a number ul international netwoi ks
and coalitions have bern formed. Their goal is to
revitalise comprehensive PHC and to work to
wards a healthier, more equitable, more sustain
able approach to development . Two of these
coalitions, which have both participated in organ
ising the People's Heath Assembly, are the follow
ing.
The Third World Health Network (TWHN).
based in Malaysia, was started by the Third World
Network, which has links to the International
Consumers Union. The TWHN consists of progres
sive health care movements and organisations,
mainly in Asia. One important contribution of the
Network has been the collection of a substantial
library of relevant materials, their lobby for
North-South equity and the promotion of net
working between Third World organisations.
The International People s Health Council
(IPHC) is a coalition ofg.i assroots heath piugrammes, movements and networks. Many of its
members are actively involved in community
work. Like the TWHN. the IPHC is committed to
working for the health and rights of disadvan
taged people—and ultimately, of all people. Its
i
METHODOLOGIES
of
EDDCATfOM for CHAMGE
ne of the most rewarding activities of the
IPHC was a post-conference workshop
held in Cape Town. South Alriea. on
Methodologies of Education for Change Health
educators from Africa. Central America. Mexico.
North America, the Philippines and Japan most
with many years of experience— facilitated group
activities. Each demonstrated some of the innovalive learning and awareness-raising methods they
use?, in their different countries. The challenge of
the workshop was lo design or adapt methods of
education for action to meet the new challenges
of lodny’ i globalised and polarised world
From micro to macro, local to global: ways
of making and understanding the links
The Cape Town Workshop participants agreed
that a global grassroots movement needs to be
mobilised to help rein in the unhealthy and unsus
tainable aspects of globalisation.
To do this, learning tools, methods, and teaching
aids must be developed to help ordinary people
see the links between their local problems and
i
i
Efecple's Health Assenbly
9*
I
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global powers:
:o:
People need to understand how I heir growing
hardships at homr (low wages, nnempkiyinenl, rising food prices, cut-backs in services,
growing violence, etc.) can be traced Io the
global forces that manage the flow of money
and resources in ways that make the rich
richer and the poor poorer.
Villagers and shanty-town dwellers in the
South need to understand how decisions by
wealthy, powerful men in Northern cities lead
to hunger, diarrhoea and the death of their
children.
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:o'
They need to know who is responsible for the
decisions that allocate vast amounts of money
for weapons, pet food, tobacco, golf courses
and trips to the moon, when millions of
children don’t gel enough Io eat.
They need to understand how the World Bank
and IMF put the squeeze on pool countries to
keep paying interest on their huge foreign
debt...and how structural adjustment pro
grammes imposed by the Bank and IMF—
which force poor countries to cut-back on
public services--make poor families pay for
health care and schooling.
Having become aware of the links between their
local problems and global policies, people need to
learn ideas and information about what they can
do:
They need to know what efforts aj e being
made—locally, nationally and internationalb - lo oppose lhesc harmful high-le\ el
policies and decisions.
They need to know what they can do person
ally and collectively at the local level to help
work toward the changes at the global level
that can shape a healthier world.
No one has a road map through these vital issues.
That is why Education for Change needs to be
open-ended and fully participatory. It is why the
facilitator and the learning group need to look for
solutions—or at least ways of coping—together.
This kind of learning process, in which people
learn from each other and look for.a way forward
together, as equals, itself becomes a microcosm of
the kind of equity-oriented, people-centred,
participatory environment we aspire lo achieve at
the global level.
Storytelling, role play and theatre for
awareness-raising and change
Storytelling can be an effective way to help people
understand and identify with problematic situa
tions, and consider possibilities for strategic action.
This is especially true if the story is a true one,
based on something that happened in the partici
pants’ village or neighbourhood— something they
are all familiar with and which concerns them
deeply.
Stories for change. Stories can be told in many
ways: by storytellers, as skits, as role-play or
socio-dramas, or as puppet shows. Some of the
best stories or socio-dramas for analysing situa
tions and exploring options for action are openended and constructed through the participation
of the entire learning group. After a key theme or
problem is identified, someone starts the story
around that theme, and develops it to a point of
crisis or crucial ( hoice. Then another person
continues the story, up to another crisis point.
Then yet another person continues it. And so on.
Or after the story has been developed to a critical
point, participants can divide into smaller groups,
each developing the story in a different direction.
Thus it becomes a way of brainstorming alterna
tives for action in which everyone thoughtfully
lakes part.
From stories to theatre to action. In Project
Piaxtla, Mexico, sometimes participatory stories or
role-play evolved into a plan for community
action. Health workers in training would develop
it into a theatre skit or puppet show and present it
to the whole village as ‘farm workers* theatre*. At
times this resulted in a collective course of action
io cope with the underlying problem. Below are
four examples of stories or role-play that evolved
into community theatre and finally into organised
action.1
Problem-based story: A few rich families
illegally possess most local farmland, resulting
in landlessness, exploitative share-cropping,
hunger, and high child mortality.
Theatre skit (developed from story): Poor
villages explore options of borrowing,
renting, or invading and reclaiming un
used illegally-held large land-holdings.
Consequent action: Poor farm workers
collectively occupy and farm the large
holdings. Eventually they demand legal
title, and redistribute the land among the
landless.
Results: Improved physical health (more
food, fall in child mortality) and psycho
social health (self-confidence, empower
ment. determination collectively to better
i
Ctnrnjui cation as if P=cple bettered
I
91
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llllie. pay back triple al harvest time, this leads
m big debts, increased poverty and hunger.
their lives).
Problem-based story Alcohol, brequent
drunkenness of men leads to violence family
discord and malnutrition of children (money
spent on booze).
Skit ‘Village Women Unite to Overcome
Drunkenness/ Skit first shows miserable
situation. Then women join together to close
down the ‘water holes’ (illegal bars).
Action: After the skit, when a rich man
opens a bar in the village, the women
organise a protest, demand closure ol bar
and protest against alcohol-related corrup
tion by authorities.
Results: Despite the brief jailing of health
workers, the bar is shut down. Fewer
killings. Better health. Newspaper articles
inspire women in other villages to take
similar action.
Problem-based story. Village midwives,
mimicking doctors, inject hormones (pituitrin)
to speed birth and give force to mother. This
causes needless deaths, or defects in babies.
II
1!
Skit: Scene 1: Shows mother giving birth;
hormone injected; baby born blue and dead.
Scene 2: Same mother delivers without
hormones. Baby healthy. Audience explains
why.
Action: Midwives and mothers jointly
decide: No Hormone Shots For Normal
Births
To reduce bleeding, mothers breast-feed
newborn babies at once (to free natural
hormones).
Results:
Fewer rup
tured uteri;
fewei epllep
tic, dead or
brain-dam
aged babies;
demystifica
tion of mod
ern medi
cines; more
appreciation
of the body’s
own abilities.
Skit: Shows how high interests on maize
loans devastate poor farming families.
Then families come together to form a co
operative grain bank—with success.
Action: Health workers help villagers stait
the co-operative maize bank, which loans
grain at low interest rates. They also build
rat and insect-proof storage bins.
Results: The maize bank pulls poor farmers
out of debt. Eventually they are able to
produce surplus grain and have no need
borrow. Better fed. healthier children; fewer
die.
i
Stories linking local problems to global
WlIiMlu abovv series am! skits proved useful in
lheii .lav tie v are elated. They focused on local
problems that io a large extern had local solutions.
For example, landless villagers could jom togelhet
and -reclaim land-holdings that were illegally
large. But today many of the people s most disa
bling problems have their roots in international
trade and the global economy. In preparation lor
the North American Free Trade Agreement
(NAFTA), the Mexican government was forced to
change its Constitution. Agrarian Reform laws,
which had protected the land rights of poor
farmers were annulled. As result, poor farmers are
losing their ancestral land. Two million have
migrated to city slums, where the glut of jobless
workers has reduced real wages by 40%. Resulting
hunger and despair have led to a wave of crime
and violence. The village of Ajoya (where the
above stories and skits helped people solve earliei
problems! hie, had 10 kidnappings. Irequenl
killings, and repeated hold ups of buses. In then
curienl . .immunity diagnoses’, villagers see crime
and violence as among their biggest health-related
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problems.
Similar situations now exist worldwide A few
years ago, when Mexican school-aged children did
their own ‘community diagnoses , they identi let
problems such as diarrhoea, coughs, skin sores
and ‘being too thin' as their biggest health-related
problems. But today—whether in Mexico, the
Philippines. Pakistan. South Africa, or the slums of
Chicago (USA)—children tend to identify as their
biggest health-related problems such things as
5®
Prob
crime, violence, drunkenness, drugs, fighting
lem-based
within families, beating of children and similar
story: Poor
social issues These symptoms of system failure
families
borrow maize and social upheaval can often be traced to the
global policies that are deepening poverty,
from the rich
undermining wor kers’ rights, reducing jobs and
al planting
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wages, and cutting back on public services.
7
- People in pojor communities around the world
suffer the effects of these global policies, often
without even knowing such policies exist. They
have little awareness ol how decisions made by
overfed men in suits sitting around a table at the
World Bank translate into fewer health services
and more costly medicines for their sick children.
At a jf )]
global
level?
What \\
In preparation for the People's Health Assembly,
persons involved in community health activities
(and in all sectors affecting the well-being of
people or the environment) are being asked to
collect eye-opening stories that make this kind of
‘micro-to-macro’ or Tocal-to-global links. One
example of such a story—called The White
Death—is included in the Preparatory Packet for
the PHA (and is briefly summarised in this paper).
The ‘But why? game’ and the ‘chain of
causes’—used with stories for situational
analysis
Of various participatory learning methods to raise
awareness of the root causes of poor health, ones
involving situational analysis of a true story have
proved successful in many countries. The process
is in four parts:
I
2.
I
'The Story of Luis’—presented in the handbook,
Helping Health Workers Learn—has been used
effectively as a teaching tool in health programmes
around the world. Based in a Mexican village, this
true story unveils the chain of causes that lead to
a boy’s death from tetanus.2
The ‘But why?’ game (an example analysing a
child’s death from diarrhea). After the story to be
analysed is told, the facilitator asks a series of
questions and participants answer. In response to
each answer the facilitator asks 'But why?'. Here is
an example of how the 'But why?' game might
develop from a story of a child's death from
dehydration due to diarrhoea:
The story portrays a series of events that lead
up to a tragic ending, such as the death ol a
child. (People’s attention is captured better if
the story is based on a recent, local sequence of
events, which everyone is familiar with.)
1
After the story, participants play a (usually
very serious) ‘But why? game, to itemise and
analyzing the series of factors leading up to
the child's death
3. Then they collectively build a chain ol causes
linking the sick child to the grave
4.
/✓/)
_ /I
is the
likelihood of
success
fully breaking different links?
:<•>; What are the preparations and resources
needed? What are the risks?
2® With which links can we most effectively
begin to take action?’
For the new ‘macro-problems’ of the 21st Cen
tury, new kinds of awareness-raising stories are
needed—stories that make the links between
local problems and global events; stories that
build a chain of causes from shanty-town hard
ships to global boardrooms.
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Finally, the group discusses which links of the
chain they may be able to break in order to
prevent similar loss of health and life in the
future. They ask themselves:
:<•>: Which links can be broken by the in
formed action of a concerned individual?
Which links require action at the family
or community level?
Which require action at a national level?
Juanita died from dehydration.... But why?
‘Because she had severe diarrhea.' ... But why?
'Because she swallowed harmful germs. ... But
why?
‘Because the family didn't have a latrine or
clean water.' ... But why?
‘Because her father had no money to install
them.’ ... But why?
‘Because, as a share-cropper, he had to pay half
his harvest as rent?’... But why?
‘Because he didn't own any land himself.' ...
But why?
‘Because the government failed to enforce the
Agrarian Reform laws.' ... But why?
‘Because rich land barons bribe politicians, and
no one stops them.' ... But why?
When one series of causes is exhausted, the
facilitator can ask questions exploring another
series. A sequence of questions may lead from
local to national factors (as above), or even interna
tional ones (as below). Note that answers need not
come only from details of the story; participants
can also draw on their own observation, knowl
edge and previous awareness-raising discussions.
Cfcnrrunicaticri as if Pscple Mattered
I
^3
Oral rehydration therapy (ORT) can help
prevent death from dehydration. Yet Juanita
didn’t receive ORT ... But why?
pants may have knowledge of local events or
factors not included in the original story. These
add important new dimensions.
Because her mother couldn't afford commer
cial packets of oral rehydration salts (0RS), and
hadn't learned to make a low7cost rehydration
drink at home.’ ... But why?
‘Because the government, which used to give
ORS packets free to poor families, now makes
people pay.' ... But why?
‘Because the World bank required that health
ministry introduce r",;t recovery by ( barging
for medicines and sei vices.' ... But why?
‘Because our country has a huge foreign debt
and has to pay by cutting benefits to the poor.
... But why? ... Etc.
Discussion and debate and the airing of different
opinions—are encouraged. The purpose of the
activity is to help participants explore issues in
depth and form a comprehensive, multidimen
sional picture—like fitting together pieces cf a
I
puzzle.
Some partit ipants may argue that building a linear
chain of causes is simplistic, that causal factors
inieiliiik -n hi.kiv ways, more like a web than <1
s.Mu.p.ugiamines prefer to build a mosaic
on a blackboard rather (han connecting cardboaid
links. Teaching methods (like oral rehydration
technology) can always be improved. Group
criticism and collective improvement of the teach
ing methods should be actively encouraged, ns,
too. is ‘education for change .
Building the chain of causes. To extend the
situational analysis of the 'But why? game, the
learning group can build a chain of causes. To
make learning more dynamic, large links can be
cut from cardboard. To add to the depth of the
analysis, five categories of links can be labelled as:
PHYSICAL (things)
BIOLOGICAL (worms and germs)
CULTURAL (attitudes and beliefs)
ECONOMIC (money)
POLITICAL (power)
To these five—because H Is increasingly impoitant
in the causal chains—some folks add:
Breaking the links. Perhaps the most important
part of the ‘chain of causes' activity is the follow
up discussion about WHAT TO DO. Studying the
causal chain, the group considers which links
they may be able to break and what action to
take. Some links can be broken through individual
action (such as a mother learning to make a
homemade rehydration drink). Other links may
require community action (such as putting in a
,ommunal potable waler system). Yet others may
requne joining national or international networks
or co ililions (such as participation in the campaign
of I h'.illh A< Hon International to restore the right
to free essential medicines to families too poor to
pay).
ENVIRONMENTAL (nature of our surround
ings)
Two additional figures can be made of cardboard,
one representing the sick child and the other a
tombstone. These figures are attached to a wall (or
trees) about two metres apart. With the cardboard
links, the group builds a ’chain of causes' from the
child to her grave. Each participant has one or
more cardboard links. The story is told again,
using the method of the ‘But why?’ game. Each
time a cause is stated, a person with a correspond
ing link (for examj
Eventu
and hooks her link into the growing chain. Eventu
ally the chain extends from child to grave.
The process of participatory analysis. Though the
story may be based on t he death of a real i hild and
a sequence of real events, the process of analysis,
with construction of the causal chain, can and
should be somewhat open-ended. The sequence of
causes (both in the ‘But why?’ game and using the
cardboard links) can develop in a variety of
directions, following the lead of the group. ParticiEtecple's Health Asserbly
Examples ofstories with local-to-global links:
'The White Death' and The Story ofSam
The packet of materials for the People s Health
Assembly titled ‘Invitation to Participate in Pre
Assembly Activities.' includes as examples three
stories that make local-to-global connections. The
first two, 'The White Death' and ‘The Story of
Sam.’ are designed to be followed by 'But why?'
and ‘chain of causes’ activities.
'The White Death’ is adapted from a slpry develuped with village women in Sierra Leone, Africa.
Il tells of a woman who becomes ill and (irjally
dies hi.ii 'weak blood' (anaemia), identified by
the women as their most important health prob
lem. and the biggest killer of women. 'Through
group discussions and use of innovative leaching
aids (such as a mosquito made from syringe and
bits of a tin can) the women came to realise that
‘weak blood' has many interrelated causes and to
understand why it kills more women than men.
1
Z
Xc7
!
1
They found the causes for ’the white death range
from LOCAL to GLOBAL and from BIOLOGICAL
(e.g., malaria) to CULTURAL (e.g. men have first
grabs atjavailable meat) to ECONOMIC and
POLITICAL (e g. to produce money lor foreign
debt payment, the country is required by the
World Bank to cut down native forests that used to
have iron-rich game animals and herbal cures lor
malaria).
By piecing together this story from their own
collective experiences, and then retelling it using
‘But why?' questions and a ‘chain of causes, the
women gained better understanding both of thenown bodies and of the links between their local
health problems and global economics
With their new knowledge about the multiple
causes of weak blood, the women were better able
to take personal actions^ as growing and eating
blood-strengthening foods, and collective action
such as joining the growing trans-African move
ment to require the World Bank to be more re
sponsive to human and environmental needs.
Stories like ‘The White Death' and 'The Story of
Sam -and other stories that are pieced together
locally around common concerns—can help
ordinary persons understand how their local
hardships are linked to global forces. Analysis of
the stories can help prepare people to take mean
ingful part in the growing worldwide debate
about how economic and development policies
should serve human and environmental needs,
and how to make high-level decisions more
transparent and more democratic.
discovery-based learning—and
LEARNING BY DOING
The effort to make global policies socially just and
democratic will be an uphill battle. The world is
unwisely ruled in a selfish, shortsighted way by a
tiny privileged minority with huge wealth and
power. To change this situation for the common
good will require a vast united front of concerned
people. Folks from all races, nations and walks of
life—farmers and labourers; the jobless and the
underpaid; the poor, the hungry and the sick;
prisoners; illiterates, students and academics; the
middle class, and even the very rich who worry
for their children's future—must understand the
big issues and what is at stake.
But understanding the issues is not easy. As we
have already pointed out. institutionalised
disinformation is the modem tool of social
control. Schools, newspapers, television and
market propaganda are designed to keep those on
lop on top by ‘manufacturing consent’. For people
to find their way through the maze of politically
filtered information, cover-ups. and the Siren-like
incentives to conform without questioning, requires-above all else—an ability to observe and
think for oneself
To transform our top-heavy system will require a
massive uprising of peace-loving fighters for social
justice—people who can sort their way through
the beguiling veil of disinformation; and discover
for themselves what is happening around them,
for better and for worse. For such a massive
movement of thoughtful, well-informed people to
be formed, a simultaneous educational revolution
is needed, one that espouses a less authoritarian,
more liberating approach to teaching and learn
ing than most of us were schooled by.
I
Ocrrnunicaticn as if People ottered
We have mentioned the enabling educational
methods of Paulo Freire and others. A related
approach is called ‘discovery-based learning', now
much used in community health education.
Discovery-based learning encourages partici
pants to make their own observations and arrive
at their own conclusion it 1 he facilitator dues nut
push ideas into people's heads, but helps to diaw
them out. This action-packed, problem-solving
approach helps people think for themselves and
gain confidence in their own perceptions and
experience. In many community initiatives this
empowering methodology has become a basic tool
in education for change'.
Discovery-based learning and learning by doing
go hand in hand. There is an old saying:
urine and butt hole are stoppered with small
plugs. The round opening al lhe lop of I he gourd
represents the baby's fontanels (soft spot) and is
rovered wilh a small cloth.
1 he • halli-ng1' h11' 'he facililaKir is to help the
leariim).' pruup discover the signs ol dchyclraliun.
wilhmil I'‘Hing them. To do this, lhe group experi
ments with the gourd baby. They fill it with water,
pull the plug to give it diarrhoea, and watch what
happens. They observe the soli spot sink m. then
the eyes stop forming tears, and lhe urine flow
slowing down. They conclude that these signs
occur because water (diarrhoea) is flowing out.
Thus they discover lhe signs ol dehydration.
Because they discover these signs in a hands-on
way (learning by doing) and by drawing their
own conclusions from their direct observations
(discovery-based learning) they never forget it.
If I hear it, I forget it.
If I see it. I remember it.
If I do it, I know it.
To this, health educators in Latin America have
added,
If I discover it. I use. it
When teaching methods enable learners to build
on their own observations and discoveries, the
knowledge they gain is their own. They can apply
it, adapt it, and build on it more effectively. Also,
it equips participants to learn about other things
directly, to dig out the truth for themselves rather
than to swallow unchewed what teachers and TV
tell them. Thus it prepares people to be actors on
life's stage, not just passive followers. It helps
transform people living in quiet resignation into
active agents of change.
The gourd baby—a tool for teaching that
uses discovery-based learning
A classic example of discovery-based learning
involves the ‘gourd baby.’ a teaching aid to help
groups of mothers, school children, health work
ers, and others learn about diarrhoea and (he
return of liquid lost’ (ch: hydration and rehydra
tion). We include discussion of the gourd baby
here, not because of the linkage of the high child
death rate from diarrhoea to the global economy,
but because the gourd baby is such a delightful
tool for teaching community educators about an
empowering and effective way of teaching.
The teaching aid is made from a hollow gourd,
preferably the kind wilh a narrow neck separating
two round ends. (A plastic bottle will also work.)
The gourd, painted to look like a baby, has all the
‘holes’ that a real baby has (mouth, urine hole, butt
hole, and two tiny eyeholes for tears. The mouth,
Through similar hands-on experimentation with
lhe gourd baby, learners observe that to prevent
the 'habv' from dehydrating when it has diar
rhoea.' they must replace at least as much fluid as
lhe biiby is losing. (This discovery is extremely
important, since studies show that village mothers
laughl i” the Ivpiral top-down way ( Do what I
say and nun i forget!') often give rehydralion
drink to their dehydrating baby as if it were a
liquid medicine, a spoonful now and then. When
their babies die. they spread lhe woid that oral
rehydralion therapy doesn’t work. So the
underuse of ORT and corresponding overuse of
costly, useless anti-diarrhoeal medicines continue
worldwide.
Many benefits derive from lhe gourd baby meihodology. Mothers who learn about diarrhoea
management h orn (heir own observations are in a
better position to question lhe many puzzling
things they are told. For example, following
standard advice, many mothers spend their last
food money on commercial^ packets of oral rehydration salts (ORS) when they could get as good or
betlri results by giving their baby home made rice
or maize porridge with a little salt. It is impoitant
that moil er.s learn to value their own experience
and to critically question directives from outsiders
unfamiliar with mothers day-to-day circumstances, limitations, and abilities?
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tuple's Health Asserrbly
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health are put in rows on the flannel-board, the
group systematically analyses their relative impor
tance. To do this, they use small flannel figures,
representing the different characteristics that need
to be considered when weighing the relative
importance of each problem.
as INTRODUCTION fo
I
dascovery-based
learning
x
any health worker training programmes.
/\ /1 as we^ as local Scherings to resolve
J y w unmet needs, use‘community diagnosis’
or 'situational analysis' to start off the group
process of identifying and prioritising healthrelated problems or other shared concerns.
There are many ways to conduct a community
diagnosis The most successful ones tend to be
hands-on, action-based and designed to encourage
full, thought-provoking participation.
I
1
One approach to community diagnosis that has
been used effectively in many countries uses a
flannel-board and small pieces of cloth with line
drawings of different health-related problems. By
using pictures rather than written words, nonliteiale people can participate in creating a graphic
representation of the problems in their community
and evaluate their relative importance.
First the group places on a large flannel-board (or
blanket on a table tipped on its side) drawings of
all the health-related problems they can think of. If
there is no jpre-existing drawing of the problem,
the person who volunteers that problem creates a
quick sketch to represent it. It is important the
group include not just 'health problems’ or ‘sick
nesses’, such as diarrhoea and skin infections, but
also ‘health-related problems’, such as poverty,
smoking and unfair land tenure. (To help people
understand the broad spectrum of‘health-related
problems', it is often helpful to first tell a story
using the 'But why?' game and ‘chain of causes'.)
After the major problems affecting community
Little round faces represent frequency: how
often the problem appears in the community,
and how many people it affects. Everyone is
given several little faces, which they take turns
placing next to the problems they consider
most common. As more faces are added, the
group tries to agree on a pattern of relative
frequency.
Skulls represent relative severity: how likely
the problem is to cause life-threatening illness
or death. Persons place skulls of different sizes
next to problems, trying to arrange them
according to how relatively dangerous or
deadly they are.
Three little faces, with arrows from one face to
the others, represent contagion. Participants
place these figures on the problems or illnesses
that spread from person to person.
A long wiggle arrow represents a problem that
is chronic. Participants place these figures on
the problems that are long-lasting, or have
long-lasting effects (like polio).
This graphic portrait of the relative frequency,
severity, contagiousness and duration of the
problems helps the participants weigh their
relative importance in the community.
.
However, another factor also needs to be weighed:
How are the different problems interrelated?
Which problems that contribute to or lead to
some of the others problems? Participants place
pieces of yarn between problems where they
believe there are causal links. The end result is a
complex web of causes. It becomes clear that some
of the problems listed are ‘root causes’, which
contribute to many of the other prob
lems
BUT
/VHY?
The final step in this process of commu
nity diagnosis is to discuss where to
begin. The graphic representations help
the group get an overall picture of the
relative importance of interrelated
problems affecting the community’s
well-being. In constructing a plan of
action for improving their situation, the
group needs to consider:
J® What-is the relative importance of the
different problems? (As investigated
CfcnTTunicaticn as if Etecple lettered
17
I
I
easy-to iesolvHocal problems when ,
local action, i, is important not to lose sight ol du
underlying problems at the macro (oi global)
level. However, strategies Id, iaking local ac mn
on global issues require a dil lereni .ippi o.K Ii
V
involve networking or jnining ciialmons and
taking part in key demonstrations. I hey may
involve educational campaigns to raise loca .
awareness so that more people vote for politician,
who dare to take a siand for the interests and
above)
Which are the underlying problems that
contribute to many other problems. (Also
investigated above)
Which problems can be dealt with locally,
safely with limited investment and with
positive, visible results? (It is often wise to
start by taking action against problems that are
likely to have fairly quick positive solutions
that everyone can see and appreciate. Good
early results help build confidence and bring
more people on board, in order to tackle more
difficult or risk-incurring problems al a latei
needs of the common people.
chihJ-W”
Empowering cbjldren
date.)
-o;
■Io become
What are the resour. es. human and otherwise,
required to overcome the.different problems.
Seeking answers to these questions helps the
group decide where to begin. As discussed earlier,
tome problems can be resolved at the ind.v.dual
or family level, others al the community level
Many of the biggest, underlying problems that
link back to the global power structure cannot be
resolved at the local level. However, certain
coping measures may help the community cope
better with the hardships caused by the underly
ing global problems.
For example, faced with privatisation of health
services or the introduction of user fees, a villag
might set up a community ‘health insurance p an
That way the whole community helps pay t ic
emergency medical costs of one of its members,
when disaster strikes.
Faring Agents of
CtUNGE
he children of today are the social archi
mcts ol tomorrow, if c hildren are to grow
up to be independent thinkers and com
passionate agents of change, they need to be
encouraged to learn from experience and to di aw
conclusions from their own observations, not jus
to memorise lessons and do what they re told,
they are to help construct a more healthy, more
caring world, children need a learning environ
ment based on co-operation rather Hum compeu
lion, where helping one another to
nmeiher--and giving friendly assisiame o those
wlio might fall hehlnd-is valued moie than
I’ellliq?, I< P
Although it is often wise io begin by alia< king
( hild lo Child is an innovative educa
tional methodology in which school-aged
children learn ways to protect the health
(jNDIrT is TOO
^^hbToEsN’T SET enough to eat.
her parents
/That'S A good answer w«o has
(another ONE ’WHY DOESN'T IND/RA
GET
X_________________
ARE IN
DEBT
enough
TO EAT ?
J
Child to-Child does much more than
impart information to kids about common
health problems. At best, it is a liberating
experience that helps children learn to
think for themselves and work together to
create a healthier, more caring environment Children learn to reach out in a
ft ienrllv. helpful way to those who are
iitosi vulnerable.
THERE
NOT ENOU«H
RAIN. >
HER fflOTHER
DOESN’T
BREASTFEED
HER.
I
the USA and Canada.
HER FATHER
IS SICK.
<
and well-being of other children, espe
cially those who are younger or have
special needs. I aumhed during lhe
International Year ol the Child in 1979.
Child-to-Child is now practised in over OU
developing countries as well as in Europe,
i
i
^SHE HAS
K Diarrhea
People's Heslth Asssrbly
^8
I
1
don't
YOU
THINK IT'S
ABOUT TIME
V/E TALK
)
THINGS OVER
as equals^
I
Child-to-Child emphasises learning through
(’xpt’i iencc (The gourd baby as a lool for ‘discov
ery-based learning' w.is first developed through a
Child-to-Child activity.) Rather than simply being
told things, children conduct their own surveys,
perform their own experiments, and discover
answers for themselves. They are encouraged to
think, observe, explore, analyse and invent. This
makes learning an adventure, and fun. Children
develop wavs of looking critically and openly at
life. The a< tivilies encourage independence of
thought and co-operative spirit that helps form
leaders in the process of change.
In Child-to-Child. children learn to work together
and help each other. Older studentd organise to
help teach younger ones. Younger ones conduct
activities (storytelling, puppet shows, seeing and
hearing tests) with pre school children. Everybody
teaches and everybody learns from each other.
Child-to-Child is pertinent to the process of social
transformation. When introduced into schools as it
has been in many countries, it can help make
schooling more relevant to the immediate needs
and lives of the children, their families and their
communities 11 introduces methods of ‘education
lor change into the classroom, counteracting and
undermining the authoritarian, conformity
building. status-quo-conserving role of the con
ventional school system.
Latin America has taken the lead in introducing
'education for change methodology into the
Child-to-Child process. Typically, a group of
children starts off by conducting their own ‘com
munity diagnosis’ (as described above). Or they
build chain of causes' stories (or draw composite
pictures of our-community' to explore the interre
lated problems in which they live.
of the world, in the process of their community
diagnosis, now tend to say that their most impor
tant problems affecting their well-being are
violence, gangsters, drunken parents, fighting
between parents, and cruel treatment by adults.
This ‘diagnosis’ makes it much more difficult for
the children to take a lead in corrective action on
their own. However, the mutual understanding
and support that comes from sharing their com
mon concerns can be of great assistance to children
who fell lost and forgotten in a world where
money rules and where democratic principals,
human rights, and basic needs are grievously
neglected.
Child-to-Child is important to the process of social
transformation because it helps children develop
skills and values based on kindness, understand
ing. defence of the underdog, and the joy that
comes from working cooperatively for the good of
all. It can help the children of today become more
able and compassionate architects of tomorrow.
CoNFIDtNCEo be fully healthy requires self-esteem. An
internalised low self-image is one of the
biggest obstacles to the full participation
and involvement of people who have been
marginalised, disempowered and kept in a subser
vient role. They have been told so often that they
are worthless and ignorant and lazy that they
begin to believe it. Their lack of respect for their
own qualities prevents them from joining in the
struggle for fairer social structures.
We mentioned above how children in many pails
For this reason, education for change' puts a lot of
Osnrrunicaticn as if Etecple Nattered
emphasis on confidence-building. It values and
builds on the experience, ideas and opinions
participants. It helps villagers rediscover vali t.
lheir traditional beliefs, customs and forms ol
healing. It demonstrates that the knowledge^
understanding and compassion of mdividua s
who cannot read or write can be as imPor^ 'o
sustaining health as the knowledge and abilities o
highly trained professionals.
People with little formal education to help them
stand up for their rights must free themselves from
the low self-image that has been thrust uponi hem.
They need to discover that they have a wealth of
knowledge, skills, and human qualities, which
privileged folks often la. k. To provide new ms.ghl
and build the self-confidence of underpr.vl eged
people, stories that tern, marily revise so. tahok ,
(as in Charles Dickens ' I he Prince and the Pauper') are especially helpful.
Fables for building confidence and self-esteem:
an example. In the mountains ol western Mexico
village health workers in training often began with
low self-esteem. They saw themselves as too
'backward' to master even the most basic skills
health professionals. Doctors in the city ospi
tals-as if by God's will-were somehow smarter,
better and more gifted than they were. From their
limited exposure to school (for those who had any)
they felt more comfortable passively memorising
facts than actively learning through an openended. problem-posing process based on their
own knowledge and experience.
who survived the disastei
arrives at our mountain
village. Exhausted and
hungry, he has only the
clothes on his back.... How
would you treat him?
Well, we’d give him some
thing io eal. We d probably
invite him to stay in one of
our huts until he figures out
Villagers:
what to do.
Why would you i Io iluil ’
l-iK Illi.Hi>l
When a person needs help,
we do what wr < an. I yen
for a stranger. If we d'idn l
help each other in.hard
limes, we wouldn I survive
VI Hag1 ■r-'
Suppose the doctor, lost
without hiJ> medicines and
hospital, decided to plant
maize (corn) on the
mountainside, like you folks
Facilitator
do?
Villagers:
wilh a machete, poor guy.
I've seen those doctors
hands: lheir soft as silk!
He'd gel blisters in no time!
And he doesn’l I.now- the
poisonous snakes, scorpions
and stinging U’t*,s 0’ which
For trainees with a low opinion of themselves and
their abilities, the following fable-deveh>r,ed
through group discussl u -about a dm un in
distress, proved enlightening.
Facilitator:
He couldn’t do it! Not
without help. First, he’d
have to cut down the brush
wild fioils ate edible I )i
which cactus have drinkable
water. Or how to keep the
insects, birds and peccaries
from eating his crops.
Alone, he couldn’t make it!
Suppose a huge hurricane
has destroyed the coastal
city. Days later a doctor
Facilitator: And would you
help him learn to farm9
.
h would be lots ul
Villagers.
work.... I.ike leaching a kid.
Il lakes a person years to
learn how to survive in
these hills.
Bui you would
fl I
him?
I I Villagers: We couldn't just
Facilitator:
help
I
let him die!
Facilitator:
tuple's Health Assarbly
too
For helping him
I
survive, how much would
you ask him to pay you?
Villagers:
Facilitator:
To pay? How could we?
You said he arrived with
nothing.
You are very kind! ... Now
let us imagine that tomor
row one of you breaks a leg.
So you go to a doctor in the
city. If you don't have any
money, will he treat you?
Villagers:
No way! ... That's true. My
mother died' because we had
no money to pay the doc
tor!'
Facilitator:
And yet you would help the
doctor who has nothing,
after the hurricane?
I
Villagers (after muttering among themselves):
‘Spose so.
This sori of awareness raising dialogue helps
people with little formal education realise they
have a wealth of life-protecting knowledge, skills,
and values—different from the ‘highly educated,'
but no less important. It helps them discover a
new sense of self-worth and take pride in their
own qualities and experience. The self-confidence
they gain lets them stand up to others as equals,
and breonv' at lors in building a mon' equitable
and compassionate society.
CONCLUSION:
•fo transfers®
WORLD
A a J hen. 40 years ago. Paulo Freire wrote
1 /\ J that with critical awareness disadvan
V V taged people can 'transform the world’,
social scientists said he spoke metaphorically.
Transform the world' meant to change and
improve your local situation, your immediate
surroundings. No doubt, our own back yard
remains a good place to begin. In the words of E.
F. Schumacher, 'Start small!'
But the world has changed since Freire's time.
Globalisation— with its hazardous trade agree
ments, structural adjustment policies, cut-backs of
public services, and institutionalised neglect of
those in need—has made comprehensive change at
the local level harder to achieve. Disadvantaged
people—even nations—have less and less voice in
decisions that shape their well-being.
Freire's insistence on ‘transforming the world' was
in some ways prophetic. Today, for local commu
nities to overcome the injustices and inequities that
diminish quality of life, they must join the grow
ing international grassroots struggle literally to
CHANGE THE WORLD. Not until the world's
resources and power are more fairly shared, can
sustainable well-being for all—or for anyone—be
achieved.
To transform the world’s power structure, we the
world s people, in all our marvellous diversity,
must learn to respect our differences and embrace
what we have in common. We must work to
gether as a family: locally, nationally and interna
tionally. To build the global solidarity we need,
we must first of all find ways
to communicate truthfully and
directly, relying not on the
mass media but on the media of
the masses.
I
I
The Internet, for those with
access to it, provides an avenue //S'
for fast and free (potentially
f
o
liberating) communication. No /, .? (
llJ
less important are the communjr • ( , :- I")
cation tools of less privileged
( L1
folks: storytelling, street theatr^i
“~l
<G. J /I
neighbourhood'rags,'awareness-raising comics and novellas, community radio and TV,
CtrrrTunicaticn as if Ffecple lettered
I
1
and the alternative press. As the Battle in Seat
made clear, well-planned protests, demonstra
tions, open forums and strategic civil disobedience
also have their time and place. Such organised
resistance serves not only to impede abuses of the
power structure, but to raise awareness of mote
it must be much more ihan ;i single mu ling ol (i()
or so people who fly m Bangladesh in Oeceinbc.
2000 Preparatory activities and follow-up ai
important as the December meeting itself, and
need to be oriented towards educauon and action.
We cannot transform the world in a day-Years of
organised struggle will he needed to bmld the
kind of compassionate, foresighted, glub.il demo
racy in which solidary .li-iends diversity and
safeguards the sustainol h- well-being ..I Hu.- planei
and its people.
In building the foundations of action for change,
education of children-and of us grown-ups. too
is essential. The best education is not only free,
but freeing. It gives people tools lor independei
thought and social responsibility. It enables people
to discover what makes our social order tick, and
then to figure out a course of action to help im
prove the situation in which we co-exist.
1 Jne Of the most impoi taut aspects of the PHA.
with its pre and post-assembly activii.es. is what
I l ( in ailed critical awareness-raising,
um' wh.-ne.mugh people Horn all . ...... t.^sa d
.
.
li. hl . of endemor become patnlully
nw.ui .,! .h. normous injustices and ...equities ol
our present global system-and the dangets hes
inequities bear lor our common futun - <a
eollecticely tip the scales of the global agenda o
put the needs of the many before the greed of
I
privileged few.
Notes
I
by David Werner and Bill Bowei
|.oi details aboul the ineilimls ol sn.i v _idln>}t
The transformation of our schools (and colleges
and universities) into centres of education for
change is essential for social transformation. This
is why Child-to-Child—with its participatory,
problem-solving, child-led approach-is so impoi
! .Xl^ fh* •» covered in Qu^n,
Tire
yoiitn s r./ r><muy Health Care and Child Survival.
tant.
But we also need adult - io adult (and adult m
child) activities that hi I r. diverse penpie lugeihei
for the common good. At all social levels cuttin8
across the divisions of race, class, age. gender and
areas of concern—people need to identify common
ground and take collective action for change.
The role of non-government organisations is
critically important. NGOs concerned with human
well-being and with environmental protection
need to work together. NGOs in a range of fields
need to form networks and coalitions to take the
unified action needed to have an impact on gio a
decision-making. The International People s Heath
Council is one such coalition.
The People’s Health Assembly promises to be a
big step forward. But if it is indeed to contribute m
creating a healthier world in these dilli' ult times.
vitality, winter 1991/92
Kcple's Health Assertoly
o'
Ab10ioBMa.Kled.oto.byualidng.
Uta,
Hea|.h C... a.H> Child SB.vh.il-. *'<l -N'.»b’"h A
Organization, the American Pediali ic Assonam o Hu
American Medial Writers Awncialimi. Gugg. ..l-e.m. and
Macarthur Foundation, among others. He is a luundu g
member and North America coordinator ol the bm-rnanonal .
People's Health Council, co-founder and Directoi of
I IrakhWrlghts (Workgroup for People s Health and Wnght.).
111K| ii Visiting Professor at Boston University Internationa
S« bool ol I'uhlic I lealth.
I
j
I
SOCIAL
SCIENCE
------ &--------
PERGAMON
Social Science & Medicine 54 (2002) 1621-1635
www.elsevier.com/locate/socscimed
I '
ti
MEDICINE
Social inequalities in health within countries: not only an issue
for affluent nations
Paula Braveman3’*, Eleuther Tarimo5'1
Department oj Family & Community Medicine, University of California, Room MU-306 East. 500 Parnassus Avenue.
Box 0900. San Francisco. CA 94143-0900, USA
b Consultant. Ministry of Health and Child Welfare. Harare. Zimbabwe
Abstract
i
I
!
1
While interest in social disparities in health within affluent nations has been growing, discussion of equity in health
with regard to low- and middle-income countries has generally focused on north-south and Z>enveew-country
differences, rather than on gaps between social groups within the countries where most of the world’s population lives.
This paper aims to articulate a rationale for focusing on within- as well as between-country health disparities in nations
of all per capita income levels, and to suggest relevant reference material, particularly for developing country
researchers. Routine health information can obscure large inter-group disparities within a country. While appropriately
disaggregated routine information is lacking, evidence from special studies reveals significant and in many cases
widening disparities in health among more and less privileged social groups within low- and middle- as well as highincome countries; avoidable disparities are observed not only across socioeconomic groups but also by gender,
ethnicity, and other markers of underlying social disadvantage. Globally, economic inequalities are widening and,
where relevant information is available, generally accompanied by widening or stagnant health inequalities. Related
global economic trends, including pressures to cut social spending and compete in global markets, are making it
especially difficult for lower-income countries to implement and sustain equitable policies. For all of these reasons,
explicit concerns about equity in health and its determinants need to be placed higher on the policy and research
agendas of both international and national organizations in low-, middle-, and high-income countries. International
agencies can strengthen or undermine national efforts to achieve greater equity. The Primary Health Care strategy is at
least as relevant today as it was two decades ago; but equity needs to move from being largely implicit to becoming an
explicit component of the strategy, and progress toward greater equity must be carefully monitored in countries of all
per capita income levels. Particularly in the context of an increasingly globalized world, improvements in health for
privileged groups should suggest what could, with political will, be possible for all. © 2002 Elsevier Science Ltd. All
rights reserved/’
Keywords: Equity; Social inequalities in health; Developing countries
5
Background: wide and widening health inequalities within
low- and middle- as well as high-income countries
t
I
♦Corresponding author. Tel.: +1-415-476-1259; fax: +1415-476-6051.
E-mail address: pbrave@itsa.ucsf.edu (P. Braveman).
1 Formerly, Director, Division of Analysis, Research, and
Assessment, World Health Organization, Geneva, Switzerland.
Over the past decade, there has been a growing body
of research and commentary on socioeconomic inequal
ities in health in western Europe and the United States
(Bartley, Blanc, & Montgomery, 1997; Braveman, Oliva,
Reiter, & Egerter, 1989; Braveman, Egerter, & Marchi,
1999; Gilson, 1998; Kaplan, Pamuk, Lynch, Cohen, &
Balfour, 1996; Kennedy, Kawachi, & Prothrow-Stith,
0277-9536/02/S-see front matter (g) 2002 Elsevier Science Ltd. All rights reserved.
Pll S02 7 7-95 36(0 1 )OO3 3 I - 8
i©2
Q.
viii
CONTENTS
Social Environment and Behavior
A Public Health Success: Understanding Policy Changes Related to Teen
Sexual Activity and Pregnancy, Claire D. Brindis
An Ecological Approach to Creating Active Living Communities,
James F Sallis, Robert B. Cervero, William Ascher, Karla A. Henderson,
M. Katherine Kraft, and Jacqueline Kerr
Process Evaluation for Community Participation, Frances Dunn Butterfoss
OD
y
(/) C
Eg
s £■
co
•ss
O§
Qo
o
r- c
<O «3
<N 2
11
.2 2
1>
(X, c
>
D
V >>
Shaping the Context of Health; A Review of Environmental and Policy
Approaches in the Prevention of Chronic Diseases, Ross C. Brownson,
Debra Haire-Joshu, and Douglas A. Luke
Stress, Fatigue, Health, and Risk of Road Traffic Accidents Among
Professional Drivers: The Contribution of Physical Inactivity,
Adrian H. Taylor and Lisa Dorn
The Role of Media Violence in Violent Behavior, L. Rowell Huesmann and
Laramie D. Taylor
Health Services
Aid to People with Disabilities: Medicaid’s Growing Role,
Alicia L. Carbaugh, Risa Elias, and. Diane Rowland
For-Profit Conversion of Blue Cross Plans: Public Benefit or Public Harm?
Mark A. Hall and Christopher J. Conover
Hypertension: Trends in Prevalence, Incidence, and Control, Ihab Hajjar,
Jane Morley Kotchen, and Theodore A. Kotchen
Preventive Care for Children in the United States: Quality and Barriers,
Paul J. Chung, Tim C. Lee, Janina L. Morrison, and Mark A. Schuster
Public Reporting of Provider Performance: Can Its Impact Be Made
Greater? David L. Rabinowitz and R. Adams Dudley
Health Disparities and Health Equity: Concepts and Measurement,
Paula Braveman
Z11
297
323
341
371
393
417
443
465
491
517
167
§
<
Indexes
Subject Index
Cumulative Index of Contributing Authors, Volumes 18-27
Cumulative Index of Chapter Titles, Volumes 18-27
Errata
An online log of corrections to
of Public Health
chapters may be found at http://publfibalth.annualreviews.org/
Io<t
537
565
570
I
Ml
1622
I
A Braveman. E. Tarimo I Social Science & Medicine 54 (2002)
1996; Krieger, Williams, & Moss, 1996; "
MI1,t &
Kunst
Mackenbach, 1994; Lynch, Everson,’ Kaplan.‘salone^
& Salonen, 1998; Mackenbach & Gunning-Schepers’
1997; Macintyre et al., 1989; Macintyre, 1997; Marmot
el al., 1991; Marmot, Ryff, Bumpass, Shipley, & Marks,
. 1997; Pamuk, Makuc, Heck, Reuban, & Lochner, 1998;
Pappas, Queen, Hadden, & Fisher, 1993; Roberts, 1997;
Smith, Bartley, & Blane, 1990; Smith, 1997; Townsend’
1990, 1994; Wagstaff, 1992; Wilkinson, 1992a. b; World
Health Organization Regional Office for Europe, 1994)
Gender disparities also have received increasing con
sideration In affluent countries (Council on Ethical and
Judicial Affairs, 1991; Arber & Cooper, 1999; Dunnell
Fitzpatrick, & Bunting, 1999; Fuhrer, Stansfeld, Chemali, & Shipley, 1999); scholars have pointed out the
complexity of interpreting many of the observed gender
differences (Macintyre, Hunt, & Sweeting, 1996) and
emphasized thej, importance of examining how socially
constructed gender roles and gender inequalities may
adversely affect the health of men as well as women
(Hunt & Annandale, 1999; Karachi, Kennedy, Gupta
8c Prothrow-Stith, 1999). Racial/ethnic disparities in
health and health care in the US have been routinely
monitored and discussed for decades (Braveman el al.,
1989; Braveman, Egerter, Edmonston. <& Verdon, 1994;
Breslow & Klein, 1971; Council on Ethical and Judicial
Affairs, 1990; Kochanek, Maurer, & Rosenberg. 1994;
Maynard, Fisher, Passamani, & Pullum, 1986; Montgomery, Kiely, & Pappas, 1996; Schulman et al., 1999;
United States Department of Health and Human
Services, 1985; Wenneker & Epstein, 1989; Winkleby,
Robinson, Sundquist, & Kraemer, 1999; Yergan. Flood,’
LoGerfo, & Diehr, 1987). Many scholars have pointed
out the need to consider the extent to which the
disparities were due to socioeconomic rather than to
racial/ethnic factors per se (Bassett & Krieger, 1986;
Kaufman, Cooper, & McGee, 1997; Keil, Sutherland,’
Knapp, & Tyroler, 1992; Muntaner, Nieto, & O’Campo^
1997; Navarro, 1990; Smith et al., 1998a; Terris, 1973;’
Williams, 1994; Williams, Lavizzo-Mourey. & Warren,
1994), which is made difficult by the lack of information
adequately characterizing socioeconomic status/position
in most US data sources. By contrast, discourse and
documentation on health disparities affecting the
populations of low- and middle-income countries, where
two-thirds of the world’s population resides (World
Health Organization, 1998), have most often been
limited to north-south and /;cZipce/7-country differences
(World Health Organization, 1995a; World Health
Organization, 1998). Relatively little information is
routinely available on health status or health care
disparities between better- and worse-off groups within
most countries, and particularly on how within-country
social disparities may change over time.
While routine data on within-country health dispa
rities are scarce, special studies have revealed ample
1621 -1635
evidence that wide gaps in health and health care among
different socioeconomic groups within a country are not
confined to the affluent nations (Bicego & Boerma, 1993;
Breilh, Granda, Campana, & Betancourt, 1987; Cleland
& van Ginneken, 1988; Cleland, Bicego, & Fegan, 1992;
Evans, Whitehead, Diderichsen, Bhuyia, & Wirth, 2001;
Gwatkin, Rutstein, Johnson, Pande, & Wagstaff 2000OPS/OMS, 1999; United Nanons Development Pro
gramme, 1990, 1996a, b; Victora. Barros, Huttly, Teix
eira, & Vaughan, 1992; World Bank, 1993; SuarezBerenguela, 2000). In Venezuela, for example, poorer
municipalities have had infant mortality rates three
times higher than those in other municipalities (Pan
American Sanitary Bureau/United Nations Economic
Commission for Latin America and the Caribbean,
1994) and a 1992 study revealed low birthweight- rates
twice as high in the poorest compared with the most
affluent neighborhoods of a city (OPS/OMS, 1999). In a
state of Mexico, a 9-year difference in life expectancy
was recently observed between people living in a poor
county and those in a relatively well-off county (Evans
ct al., 2001), Marked differentials in child mortality have
been demonstrated according to a range of socioeconomic factors in Ghana, Kenya. Lesotho, Liberia,
Nigeria, Sierra Leone, Sudan, Indonesia, Nepal, Re
public of Korea, Sri Lanka, Thailand, Chile, Jamaica
(United Nations, 1985), Costa Rica, Honduras, Para
guay, and Jordan (United Nations, 1991), Peru (OPS/
OMS, 1999; Valdivia, 2001), and Brazil (Victora &
Barros, 2001; OPS/OMS, 1999). Adults in non-professional jobs in Sao Paulo, Brazil, during the late 1980s
had death rates that were two to three times higher than
those of professionals (World Bank. 1993). In Bolivia,
most public spending on health services has gone toward
care for people belonging to the upper 40% of income
groups (Unidad de Analises de Politicas Sociales, 1993).
In Indonesia during 1990, only 12% of public spending
for health care was for services consumed by the poorest
20 /o of households, who would be expected both to
need more health services because of poverty’s role in
illness and to be less able to .pay, for -----health1 care in the
private sector; the wealthiest 20% of households
consumed 29% of the government subsidy in the health
sector (World Bank, 1993). In the Dominican Republic
m 1996, the poorest quintile of the population paid 20%
of their income for health care while the richest quintile
paid less than 10% (OPS/OMS, 1999). None of these
disparities would have been revealed by data routinely
collected and analyzed.
Striking gender disparities in health and/or health
care have been observed outside the industrialized
countries, again generally only as a result of special
studies (Standing, 1997). A study in India showed that
female infants 1-23 months of age were almost twice as
likely to die by the age of two as were males, and
concluded that the most likely explanation was different
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behavior of families toward male and female children
rather than biological differences (Das Gupta, 1987). A
United Nations agency report concluded that the death
of one out of every 6 female infants in India,
Bangladesh, and Pakistan was due to neglect and
discrimination (United Nations Population Fund,
1989). Studies in Bangladesh found that boys under 5
years of age were given 16% more food than girls
(United Nations. 1993). In some countries, surveys
indicate that families are significantly more likely to
immunize their male children (Kurz & Johnson-Welch,
1997: Martineau, White, & Bhopal, 1997; Sommerfelt &
Piani, 1997). Examples of bias against girls in access to
modern health services have been cited from Korea,
Togo, Sierra Leone, Nigeria, Jordan, Algeria, Syria, and
Egypt (Kutzin, 1993). A recent study in Chile found that
women paid more for health care in both the public and
private sectors because co-payments/uncovered expenses
were greater for many reproductive health services used
only by women but affecting the health of the entire
society (Vega, Bedregal, & Jadue, 2001).
Racial/ethnic disparities in health and its determi
nants also have been observed within countries of
diverse per capita income levels. In Guatemala, mal
nutrition rates during the 1980s were 40% higher among
indigenous compared with non-indigenous children
(Psacharopoulos, Morley, Fiszbein, Haeduck, & Wood.
1993). Studies of child mortality have demonstrated
ethnic disparities within Peru, Sri Lanka, Thailand, and
many African countries that persist even after control
for other factors including some measures of socio
economic status (United Nations, 1985). Until recently,
more than four times as much money was spent on
health care for whites as for blacks in South Africa
(Yach & Harrison, 1995); reversing the health effects of
apartheid is unlikely to be an easy or rapid process
(Benatar, 1997). The likelihood of a child dying before
reaching age two varied between ethnic groups in Kenya
from 7.4% to 19.7%, and in Cameroon from 11.6% to
20.5% (World Bank, 1993).
In contrast with the lack of routine data on socio
economic, gender, and ethnic disparities in health,
urban-rural disparities and disparities between large
subnational regions of developing countries are often
relatively well documented on a routine basis. Jn
Nigeria, the average life expectancy in the Borno region
is only 40 years, 18 years less than in the Bendel region;
adult literacy (12%) in Borno is one-quarter of the
national average (United Nations Development Pro
gramme, 1994). In Peru, the infant mortality rate in
some rural areas was recently estimated at 150 per 1000
live births, while in the capital city Lima it was 50 per
1000 (Pan American Sanitary Bureau/United Nations
Economic Commission for Latin America and the
Caribbean, 1994). Urban-rural gaps may be widening
in many nations, along with disparities between different
1623
zones within the same city. For example, in Latin
America between 1980 and 1994, the proportion of
urban dwellers who were poor increased from 25% to
34%; the urban poor are now thought to make up the
greatest segment of desperately poor people in the
region (OPS/OMS, 1999).
What is equity in health?
Equity is an ethical concept that is as challenging to
define precisely as its near-synonym social justice, which
may mean different things to different people in
different societies at different times. Inequity refers not
to all inequalities, but to those inequalities that are
considered unfair and avoidable (Whitehead, 1990).
Equity implies that need rather than privilege be
considered in the allocation of resources; as with equity
and fairness, it is difficult to define need in precise terms
(Mays, 1995; National Health Service Management
Board, 1988). In operational terms, pursuing equity in
health can be understood to mean striving to reduce
avoidable disparities in physical and psychological well
being—and in the determinants of that well-being—
that are systematically observed between groups of
people with different levels of underlying social privi
lege, i.e., wealth, power, or prestige. The fact that an
avoidable health disparity adversely affects a group at
an underlying social disadvantage makes that disparity
unfair, even in the absence of knowledge of the specific
proximate causes of the disparity. In virtually every
society in the world, social privilege varies among
groups of people categorized not only by economic
resources but also by gender, by geographic location, by
ethnic or religious differences, and by age; other
dimensions can be important'as well, but these are
nearly universal and they often interact with each other
to make some groups—e.g., poor women in ethnic
minority groups—particularly disadvantaged with re
spect to opportunities to be healthy.
Assessing health equity within a society requires
examining inequalities in health (and in its determinants)
between more and less socially advantaged groups
within the society, focusing for practical reasons on
those inequalities likely to be among the most important
causes of ill health and also to be relatively avoidable.
Thus, a rational focus on equity would lead one to
prioritize the goal of trying to diminish gaps in ill health
due to, for example, diarrheal disease, malnutrition, or
adverse environmental exposures that, disproportio
nately and significantly affect disadvantaged groups;
by contrast, less emphasis would be placed dn searching
for cures for rare genetic conditions that affect one
ethnic group more than another, even though one might
believe that ultimately all genetic conditions will be
curable or preventable. It would make little sense from
ifet *
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P. Braveman, E. Tarimo I Social Science & Medicine 54 (2002) 1621-1635
an equity perspective to focus attention on reducing the
widespread but genetically based gap in birth weight
between male and female newborns, because it is
unlikely to be a major source of subsequent health
inequality, avoidable, or related to underlying differ
ences in social advantage.
• “Social inequalities in health” or “health inequities”
refer to avoidable disparities in health or its key
determinants that are systematically observed be
tween groups of people with different levels of
underlying social privilege, i.e., wealth, power, or
advantage.
• Virtually everywhere, social privilege varies not only
by economic resources, but also by gender, racial or
ethnic group, geographic location, and other characterisljics.
® Equity implies consideration of need rather than
social privilege in resource allocation.
• Assessing jiealth equity requires examining avoidable
disparities ’in health (and its determinants) between
more and less socially advantaged groups.
For some, a commitment to equity in health means
that all social groups should have a basic minimum level
of well-being and services, but that at the same time it is
acceptable for some social groups to have better health
status or health care than others, as long as government
does not pay directly or indirectly for the additional
benefits. There may be substantial disagreement about
what constitutes “minimum” levels of health and health
care; implications would be quite different if “mini
mum” standards meant good, borderline, or poor levels
(Jayasinghe, De Silva, Mendis, & Lie, 1998). Because
health and health care are not commodities like
furniture or automobiles, most people who promote an
egalitarian perspective would contend that equity
requires the reduction of all avoidable disparities that
significantly shape opportunities to be healthy, not only
ensuring a minimum standard for all (Gilson, 1998;
World Health Organization, 1996).
Why care about equity—in general or in health in
particular?
Evidence is accumulating in industrialized countries
of a relationship between the magnitude of socio
economic inequalities and poor health that cannot be
Fiscella & Franks, 1997; Judge, 1995). Living in an
inequitable society could harm health through many
economic, social, psychological, and physiological path
ways (Adler et al., 1994; Kaplan et al., 1996; Marmot
et al., 1997). Income disparities may be linked with
deleterious health effects in large part in so far as they
reflect varying degrees of investment in human develop
ment, e.g., in public education, health care, or other
social services (Kaplan et al., 1996; Kawachi, Kennedy,
Lochner, & Prothrow-Stith, 1997; Kennedy et al., 1996;
Lynch & Kaplan, 1997; Smith, 1996), rather than
through a direct causal link. Some scholars believe that
income disparities may have deleterious effects on health
through their association with the degree of social
cohesion (Kawachi & Kennedy, 1997; Kawachi et al.,
1997; Wilkinson, 1997) and/or through physiologic
effects of relative deprivation on those at the bottom
of the social hierarchy (Wilkinson, 1997).
Some have argued for greater equity on pragmatic
grounds. The United Nations Development Program
me’s (UNDP) Regional Director for Latin America and
the Caribbean recently stated: “In our part of the world
there is a consensus that reducing social inequity is not
only an ethical, but also a political and economic
imperative. Equity is good business.” (United Nations
Development Programme, 1996a) When he was head of
the World Bank, Robert McNamara stated that the
“pursuit of growth and financial adjustment without a
reasonable concern for equity is ultimately socially
destabilizing”. (World Health Organization, 1995a)
Soaring crime rates in Latin America in recent years
have been attributed to failure to consider the effects of
uncontrolled free-market reforms on vulnerable social
groups, along with the associated dismantling of many
state institutions (Anonymous, 1996). A recent article in
The Economist (2001) urges governments and the rich to
take measures to limit and buffer the effects of economic
inequality in order to avoid social conflict.
Other pragmatic arguments for equity in health and
health care may appeal to the self-interest of privileged
groups, for example with respect to avoiding spill-over
effects of poor health among the disadvantaged. Given
contemporary population density and mobility, neglect
of infectious disease control jeopardizes the health of the
more affluent as well as that of the poor who provide
services for them in their homes, shops, and restaurants.
Similarly, spending on public health measures such as
immunizations and control of highly infectious diseases
among high-risk groups may even yield relatively short
explained by differences in absolute levels of income or
term savings in prevention of epidemics. Failure to
poverty (Lynch et al., 1998; Kaplan et al., 1996;
Kawachi & Kennedy, 1997; Kennedy et al., 1996;
Kennedy, Kawachi, Glass, & Prothrow-Stith, 1998;
Smith, 1996; Wilkinson, 1992a, b, 1996, 1997). Some
researchers have raised methodologic concerns about
this observed relationship, however (Deaton, 1999;
address geographic disparities in quality of care can lead
to additional costs for the public sector in the short run;
for example, when primary care services of adequate
quality and convenience are not available near poor
neighborhoods, many people will seek primary care at
public sector sites such as hospital emergency rooms and
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specialty-oriented outpatient clinics where such services
are more'costly to deliver.
Some pragmatic economic arguments for equity in
health and health care are based on achieving greater
long-term economic capacity and real productivity,
which must be ■"distinguished from short-term efficien
cies. The WHO position paper for the 1995 World
Summit for Social Development stated that “investment
in health is essential for economic growth based on a
productive workforce. To achieve this, growth needs to
be accompanied by more equitable access to the benefits
of development, as inequities have severe health
consequences and pose an unacceptable threat to human
well-being and security” (World Health Organization,
1995b). For example, malnutrition and poor health
decrease worker productivity (Cornia, Jolly, & Stewart,
1987; World Bank, 1993). Similarly, the education of
girls and women has been linked with improved child
nutrition, decreased infant mortality, and lower preg
nancy rates (Bansal, 1999; Cornia et al., 1987), all of
which have been associated with economic growth.
Poverty and lack of education are associated with high
population growth rates which in turn make it far more
difficult to alleviate poverty.
However, short-term gains in efficiency are more
easily measurable than long-term societal progress; cost
effectiveness estimates are often based on outcomes
measurable on a short-term basis. At times, the most
rapid way to observe advances in indicators of overall
growth may be to give more to those who already have
the most and need the least; they are often best equipped
to be immediately productive with a given additional
input (Wagstaff, 1991). By leaving those in greater need
continually further behind, however, this approach
limits the capacity for long-term development of the
society as a whole. Scientifically sound evidence of the
aggregate “utility” of investing in equity may be lacking
because the relevant information has not been collected
or analyzed or because the impact may not be
measurable in terms of the economic indicators being
used, at least during the specified time frame. Nobel
Prize-winning economist Amartya Sen has pointed out
the importance of using health indicators themselves as
indicators of development (Sen, 1993). The traditional
economic measures of income or commodities need to
be seen as instruments toward the end of human well
being itself, rather than as ends in themselves (Sen
1998).
, /
•
Global pressures are making it difficult for countries of
every income level to achieve greater equity in health
In the face of powerful global economic, social, and
political trends, many countries are finding it difficult to
implement and sustain equity-promoting policies in
1625
sectors with major influences on health. Recent UNDP
Human Development Reports have' noted widening
income inequalities in many countries, including Argen
tina, Bolivia, Brazil, Peru, Venezuela, Bangladesh,
Thailand, Bulgaria, the Czech Republic, the Baltic
States, Australia, the United Kingdom, and the United
States of America (United Nations Development Pro
gramme, 1996b). In Latin America, absolute numbers of
people living in poverty have increased markedly since
1980 and the proportion of people living in poverty has
been stagnant overall (Anonymous, 1996; OPS/OMS,
1999) and increasing in some countries, such as Mexico
(United Nations Development Programme, 1997). A
recent Pan American Health Organization report (OPS/
OMS, 1999) stated that in 1995, purchasing power
parity was 417 times greater among the richest 1 % of the
population of Latin America than among the poorest
1%, which was the highest ratio in recorded history, and
that it probably has worsened since (OPS/OMS, 1999).
While trends over time in disparities in wealth are
relatively well documented on a routine basis, few
countries have routinely collected data that permit
examination of time trends in socioeconomic disparities
in health. However, widening socioeconomic disparities
in health status have been demonstrated in a number of
industrialized countries. The Black Report on social
inequalities in health in England showed that disparities
in death rates between employed men who worked in the
highest and lowest occupational class jobs widened
consistently from 1949 to 1970 (Black, Morris, Smith, &
Townsend, 1980). In addition to the widening gap
between socioeconomic groups as reflected by occupa
tional classes, death rales of unskilled workers in certain
age groups rose in absolute terms during the 1960s
(Gray, 1982) and 1970s (Marmot & McDowall, 1986;
Harding, 1995). These trends accompanied widening
income inequalities and occurred despite a serious
commitment to equity in health services by the National
Health Service (Smith et al., 1990). Since then, the health
gap between social classes has persisted (Marmot et al.,
1991) or widened (Scott-Samuel, 1997; Smith, 1997;
Acheson et al., 1998), while income inequalities are
“spiralling out of control” in Britain (Lewis et al., 1998;
Townsend, 1994).
Markedly widening inequalities in income in the
United States (Pamuk et al., 1998; United States Bureau
of the Census, 1996) also have been accompanied by
increases in socioeconomic disparities in various health
measures. Socioeconomic disparities in US infant
mortality rates widened significantly from 1964 to
1987—1988 (Singh & Yu, 1995). The association between
poverty and fair or poor child health status also
appeared to increase between around 1980 and around
1990 (Montgomery et al., 1996). Increases have been
observed over time in the proportion of all adult deaths
in the US that are likely to be due to poverty; some
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P. Braveman, E. Tarimo I Social Science & Medicine 54 (2002) 1621-1635
studies have concluded that the relationship between
mortality and socioeconomic status in the US has
become stronger over time (Hahn et al., 1995; Pappas
et al., 1993; Yeracaris & Kim, 1978), although appar
ently contradictory results also have been reported
(Hahn et al., 1996). Comparable observations have been
made in France and Hungary (Pappas et al., 1993) and
in New South Wales, Australia (Burnley, 1998). While
temporal association does not establish a causal
relationship, it can suggest the need for further study
and/or help confirm or disconfirm other evidence.
Even without data disaggregated by socioeconomic
group, deteriorations in health measured at the aggre
gate level have been observed recently in some countries
where income inequalities have widened and public
service safety nets have been markedly reduced. Political
and economic changes in Russia and throughout East
ern Europe have been accompanied by striking trends in
health that are evident even in national averages.
Between 1990 and 1994, life expectancy in Russia fell
from 63.8 to 57.6 years among men and from 74.4 to
71.0 years among women (Leon et al., 1997). “Accord
ing to the preliminary 1993 data available for sever
al... Newly Independent States..., life expectancy
dropped to the lowest levels seen for decades” (World
Health Organization Regional Office for Europe, 1994).
The specific direct or indirect role of income inequalities
(exerting an effect through, for example, decreased
social safety nets and/or decreased social cohesion), in
contrast to heightened violence and alcoholism that
could be related to social and political instability rather
than to economic inequalities (Kaasik, Andersson, &
Horte, 1998; Leon et al., 1997; Notzon et al., 1998;
Walberg, McKee, Shkolnikov, Chenet, & Leon, 1998)
cannot be confirmed. It appears likely that alcoholism
played an important role; abandonment of a Gorbachev-era anti-alcohol campaign may have been key
(Leon et al., 1997; Shkolnikov & Nemtsov, 1997). Some
observers have thought that economic inequalities
were likely to have had a substantial influence (Walberg
et al., 1998). Similarly alarming trends are occurring
in countries that historically placed a high priority
on equity. For example, “as an unfortunate con
sequence of China’s liberalization program of the past
decade, government funding for public health has
declined and the rural insurance system has now largely
disintegrated. A recent study suggests that these new
health policies have made the distribution of govern
ment spending for health in China more unequal and
may be contributing to an increased incidence of easily
treatable diseases such as tuberculosis” (Birdsall &
Hecht, 1995).
The costs of foreign debt repayment and economic
structural adjustment programs have resulted in cuts in
social spending in many developing countries (Kanji,
Kanji, & Manji, 1991; Lown, Bukachi, & Xavier, 1998;
United Nations Children’s Fund, 1991). These cuts have
been widely associated with deteriorating conditions
or a halting of previous trends toward improvements
for vulnerable groups (Cornia et al., 1987; Jolly &
Cornia, 1984; Kanji et al., 1991; Morales, 1993).
although some have questioned whether that con
nection is causal or inevitable (Weil, Alicbusan, Wilson,
Reich, & Bradley, 1990). In Zambia from 1980 to 1984,
when implementation of that country’s structural
adjustment program was at its height, the proportion
of hospital deaths attributed to malnutrition rose
approximately 1.5- to 2-fold among children under age
five (Kanji et al., 1991). Similarly, low birth weight rates
in Nigeria almost doubled (from 7% to 13%) at a major
hospital from 1984 to 1989 (Ibe, 1993). Women may
suffer more than men from structural adjustment
programs (Kanji et al., 1991; Jazairy, Alamir, &
Panuccio, 1993).
The effects of structural adjustment programs may be
difficult to distinguish from the effects of the economic
crises that precipitated the imposition of structural
changes in national economies. For example, during
the early 1980s many countries experienced severe
economic recessions that in themselves appeared to
have demonstrable adverse effects on vulnerable popu
lations, particularly children (Cornia et al., 1987; Jolly &
Cornia, 1984). UNICEF (Jolly & Cornia, 1984) con
ducted a literature review and 11 case studies to study
the effects of economic recession during the late 1970s
and early 1980s in Italy, the US, and selected countries
of Latin America, sub-Saharan Africa, and South Asia.
The conclusion was that, in the face of global recession,
“only in South Korea and Cuba—countries that have
deliberately implemented policies to protect children and
the poor even in times of relative economic adversi
ty—have the broad trends towards improvement in
child welfare continued almost unaffected” (Jolly &
Cornia, 1984).
Regardless of the role of structural adjustment, real
per capita public expenditures on health began to
decrease in many countries during the late 1970s and
that decline has continued. Accompanying the dimin
ished investment,
...the quality and quantity of public subsidized
health services has fallen correspondingly. Utilization
levels, particularly at rural health facilities, have
declined. Outreach services no longer function, drugs
are often unavailable, and health staff are unsuper
vised and sometimes unpaid for long periods of time.
Rural populations have faced higher costs for health
care in terms of transport and time to get to hospitals
in larger towns, or by payments to private providers
of treatment and medication. “Free” care has come
to mean unacceptably poor care. (Creese & Kutzin,
1995)
P. Braveman. E. Tarima I Social Science & Medicine 54 (2002) 1621-16-15
In Sri Lanka, for example, “there are data which
indicate that despite the state sector providing a health
service at zero user charges, 40-50% of the health care
costs are borne by the household”. (Jayasinghe et al.,
1998).
During the final decade of the 20th century most
developing country governments implemented cost
sharing mechanisms such as user fees to help finance
health services (Collins, Quick, Musau, Kraushaar, &
Hussein, 1996), often with the expectation that this
would result in improved quality as well as sustainability
of public services (Adeyi, Lovelace, & Ringold, 1998;
Creese & Kutzin, 1995). Despite acknowledging that
“there clearly are inequitable consequences in many
cases...”, some maintain that “user fees and co
payments are not necessarily at odds with equity”.
(Adeyi et al., 1998) However, some economists who
have reviewed the experience in many countries have
concluded that overall, compared with obtaining reven
ues for health services from general progressive taxation,
cost recovery in the health sector appears to be
inherently inequitable as well as inefficient (Creese,
1990; Creese, 1997). Outside of very protected circum
stances, user fees and exemption mechanisms have
generally proven to be difficult to implement without
letting the most vulnerable people suffer; furthermore,
re-investing user fees in improved quality of local
services has proven an elusive goal (Creese, 1990;
Creese, 1997; McPake, 1993). The costs of determining
eligibility for fee waivers often exceed the returns in fees
collected. When user fees were increased in Swaziland,
there was a marked decline at government facilities in
use of basic health services by patients previously
exempted for poverty, including services for diarrheal
disease, sexually transmitted disease, and infant immu
nizations; utilization remained diminished one year
later, and increases in utilization of non-governmental
facilities did not compensate for the decline (Yoder,
1989). A study in Ghana’s Volta region, where user fees
were markedly increased around 1985, determined that
during 1995, exemptions for inability to pay were
granted in fewer than 1 in 1000 patient encounters,
while 15-30% of the population were estimated to be
poor; the authors concluded that fees “are preventing
access... or are posing significant financial hardships...”
on the most vulnerable segment of the population
(Nyonator & Kutzin, 1998).
The World Health Organization’s 1978 Alma Ata
declaration on Primary Health Care voiced a global
commitment to attaining health for all; however, that
commitment to equity crystallized during a period of
widespread economic growth. During the 1980s 'and
since, economic recession has been experienced at some
time virtually worldwide, along with the economic and
political effects of globalization of the world’s economy.
Measures taken in industrialized and non-industrialized
1627
countries to increase competitiveness in the global
economy, along with structural adjustment programs
in developing countries, have led to diminished per
capita social spending in most countries. Globally, there
has been a down-sizing of government and a marked
trend toward privatization of many functions formerly
within the public domain. To varying degrees, many
countries have experienced a shift from centrally
planned and regulated to market-dominated economies.
In addition, in many nations, military spending has
increasingly devoured scarce resources that potentially
would be available for social development.
Worldwide, including in lower-income countries,
economic globalization appears to be yielding unprece
dented increases in wealth for those individuals and
population groups who are socially positioned to profit
most and most rapidly from the economic opportunities
presenting under competitive conditions (Greider, 1997;
Kanji et al., 1991; Mander & Goldsmith, 1996). The
justification for not interfering with this markedly
accelerated “the rich-get-richer” tendency in lowerincome countries is the belief that societies can break
out of the vicious cycle of poverty and underdevelop
ment only by placing the highest priority on short-term
efficiency and overall economic growth, at the expense
of social spending. The reasoning is that when adequate
rates of growth are achieved the benefits will “trickle
down” to all; according to this perspective, too much
emphasis on equity now will jeopardize economic
growth and perpetuate poverty and deprivation.
However, considerable evidence has accumulated to
discredit the hypothesis that economic growth is
automatically accompanied by benefits for all (United
Nations Children’s Fund, 1991; United Nations Devel
opment Programme, 1996b). The United Nations
Development Programme’s 1996 Human Development
Report noted that “Widening disparities in economic
performance are creating two worlds—ever more
polarized.... The poorest 20% of the world’s people
saw their share of global income decline from 2.3% to
1.4% in the past 30 years. Meanwhile, the share of the
richest 20% rose from 70% to 85%. That doubled the
ratio of the shares of the richest and the poorest—from
30:1 to 61:1; furthermore, during 1970-1985 global GNP
increased by 40%, yet the number of poor increased by
17%” (United Nations Development Programme,
1996b). The same report also commented that “Policy
makers are often mesmerized by the quantity of growth.
They need to be more concerned with its structure and
quality. Unless governments take timely corrective
action, economic growth can become lopsided and
flawed. Determined efforts are needed to avoid growth
that is jobless, ruthless, voiceless, rootless and future
less”—in other words, growth without equitable, sus
tainable human' development (United Nations
Development Programme, 1996b). Kanji et al. (1991)
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have described the emergence and consolidation of a
new class of entrepreneurs within many developing
countries, among whom gains in total national wealth
are increasingly concentrated. Anand and Ravallion
(1993) have argued that differences in social spending,
i.e., public investment in expanding human capabilities,
may have a more profound effect on health and overall
human development in developing countries than
differences in average income, and perhaps even more
profound (han direct poverty reduction when the latter
is confined primarily to changes in income.
It is difficult to obtain timely evidence of the effects of
economic and political changes on equity in health and
health care. In the first place, it is always challenging to
establish the causality of any observed pattern or trend
in health, given the complex and multifactorial path
ways almost invariably involved. Second, reliable
information to document patterns and trends in social
inequalities in health is often lacking or, when available,
not presented in a manner likely to highlight the policy
implications. Traditional methods for routine monitor
ing of health and health care often obscure large or
growing disparities between groups. In most nations,
routinely collected datg on health and health care are
rarely disaggregated meaningfully according to socio
economic factors or other markers of social advantage
such as gender and ethnicity. While poor countries often
have limited data, even in higher-income countries
routine methods of analyzing and presenting data as
nationwide, provincial, or city-wide averages obscure
large disparities between diverse groups within terri
tories. In addition, there is lack of consensus on the best
technical methods for measuring the magnitude of social
inequalities in health (Mackenbach & Kunst, 1997;
Wagstaff, Paci, & Van Doorslaer, 1991).
Conclusion: the need for international and national
organizations to focus explicitly on equity in health and its
basic determinants, within as well as between countries
International agencies could play an important role in
supporting research and action on social inequalities in
health that is relevant to the needs of low- and middle
income countries. For example, international agencies
can encourage and support national researchers from
low- and middle-income countries to apply their talents
to work in this area, and can support exchange among
researchers from different countries as well as efforts to
translate research into policy. Research methods and
suitable data sources need to be developed not only for
one-time special studies but also for ongoing routine
monitoring over time (Braveman, 1998). The Rock
efeller Foundation’s recently launched Equity Gauge
initiative is focusjng on these concerns, and particularly
on ensuring close links between monitoring and
systematic efforts for advocacy and to increase public
participation in decision-making that shapes health (see
www.rockfound.org). Globally, more knowledge is
needed about the mechanisms through which economic
inequalities damage health, apart from the obvious
effects of extreme material deprivation. However,
concern about the pathways through which relative
social inequalities affect health in the absence of
absolute material deprivation is unlikely to be perceived
as a major research priority in lower income countries,
where large proportions of the population continue to
suffer extreme material deprivation measured in abso
lute terms. On the other hand, research on the
mechanisms explaining the health effects of relative
economic disparities could contribute to better under
standing of effective approaches to mitigate poverty’s
health-damaging effects; such approaches should be
undertaken simultaneously with efforts to attack pov
erty itself at its root causes, and are likely to require
action by a range of social sectors, minimally including
education, housing, labour, and finance, not only health
services. Research is also needed to compare the costs of
different approaches to reducing health inequalities
while achieving improvements for all. While the funda
mental reasons for pursuing equity are ethical, evidence
of economic gains associated with social investment
targeting health inequalities should be documented and
disseminated; as noted earlier, an appropriate range of
outcome measures that reflect progress in human
development should be considered, including but not
limited to traditional economic measures such as
income, and the time frame for outcome measurement
must be long enough.
While the technical challenges in describing equity
and assessing the equity impact of policies are consider
able, the most daunting challenges to achieving greater
equity are of course political. Better information alone
will not produce more equity. In general, for both
national and international agencies and in countries of
all average income levels, it is far more politically
sensitive to talk about inequities within rather than
between countries. In trying to promote greater equity,
international organizations must respect national sover
eignty and cultural differences, while recognizing that
“cultural differences” can be invoked by privileged
groups to justify the maintenance of inequities in
settings where disadvantaged groups within a society
are voiceless. International organizations can support
efforts by national groups committed to achieving
greater equity, by creating forums for exchange of ideas
and experience within and between countries. In itself,
the articulation of an explicit commitment to equity by
other countries and international organizations can
boost the morale of domestic movements for greater
social justice. International- agencies also can create
forums for international exchange about equity goals
m
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P. Braveman, E. Tarimo / Social Science & Medicine 54 (2002) 1621-1635
and abo.ut policy options for achieving greater equity,
recognizing that notions of what is fair or just, as well as
preferred approaches to achieving greater fairness or
social justice, vary among different societies. As much as
one may like to prescribe what is right and wrong for
others, for practical reasons each society needs to
achieve a sufficient level of consensus about what equity
goals it will adopt, in order to move toward effective,
sustainable actions to reduce inequities; on the other
hand, it is important to note that a national consensus
may be affected by participation in international
discussions.
International agencies can undermine or strengthen
national efforts to achieve greater equity. Multilateral
lending agencies in particular must consider the shortand long-term effects on equity of the conditions
imposed on debtor nations (e.g., dismantling public
service safety nets and privatizing previously govern
ment functions), and develop approaches and criteria
that are likely to distribute the burden of belt-tightening
in a more equitable fashion than has often been the case
(United Nations Children’s Fund, 1991). Over the past
decade UNICEF and advocacy groups called upon
creditor and debtor nations to consider “debt swaps for
investment in social development programmes” (United
Nations Children’s Fund, 1991). In response to these
efforts and evidence of the impossibility of debt
repayment by many countries, the World Bank and
International Monetary Fund recently launched the
Highly Indebted Poor Countries (HIPC) initiative; in 70
poor countries, debt forgiveness is being made condi
tional on detailed plans for poverty reduction. The
obstacles are daunting and it remains to be seen whether
the initiative will result in significant social investment
effectively reaching disadvantaged groups. Domestic as
well as international development agencies need to
consider whether their actions adequately encourage
and strengthen efforts to improve equity; despite the
best intentions, development aid can be channeled in
ways that bring relatively little benefit to disenfranchised
groups (United Nations Children’s Fund, 1991). The
World Bank has recently produced fact sheets for many
developing countries, showing a range of health and
health care indicatdrs disaggregated by an indicator of
household wealth (Gwatkin et al., 2000); such informa
tion should be used routinely to assess who is—and who
is not—benefitting from development aid as well as
domestic policies. Failure to disaggregate health data
according to socioeconomic levels could result in policy
recommendations that neglect the top causes of ill health
among the world’s poorest and hence most needy
populations, for whom the communicable diseases and
perinatal conditions remain the major causes of suffer
ing, disability, and premature death (Gwatkin, Guillot,
& Heuveline, 1999). An increase in the overall amount
of funds for hon-military international assistance from
1629
the affluent nations (and particularly from those,
notably the United States, who until recently have not
fulfilled even their basic commitments (Wegman, 1999)
could contribute to increased equity between countries
as reflected by aggregate statistics; however, such an
increase might not necessarily improve inequities within
countries without systematic effort focused on that goal.
International and domestic governmental and non
governmental agencies also can provide support for bold
experiments with policies and programmes. While
rigorous evaluation of the costs and outcomes of
different specific strategies to achieve greater health
equity is scarce (Gepkens & Gunning-Schepers, 1996;
Mackenbach & Gunning-Schepers, 1997), enough is
known to suggest that action will be needed in certain
general areas (Arblaster et al., 1996; Bansal, 1999;
Bartley et al., 1997; Mills, 1998). Strategies that target
childhood well-being and development seem particularly
promising as a way to achieve greater equity in health
across the life cycle. Consideration of the available
evidence suggests that particularly under conditions of
severe resource constraints, it is likely that the following
will be needed; giving the highest priority to eliminating
absolute material deprivation; ensuring universal, com
pulsory and free education at least up to the level
required to understand and apply a health message and
to function in the national economy; ensuring safe
drinking water and sanitation for all; providing free
basic health services, including maternal and child
health services with family planning; promoting rural
development; providing micro-credit to small businesses;
favoring full employment; and generally improving the
status of women (United Nations Development Pro
gramme, 1990, 1991, 1992,'1994, 1996a,b, 1997).
Any successful strategy to address socioeconomic
disparities in health will need to be -^ased on a
recognition that the biggest threat to health equity is
overall socioeconomic inequity. The powerful relation
ships between socioeconomic position and health have
been demonstrated repeatedly (Bicego & Boerma, 1993;
Breilh et al., 1987; United Nations Development
Programme, 1996a,. b; Victora et al., 1992; World Bank,
1993; World Health Organization, 1995a, b),! even in
affluent countries (Adler, 1993; Adler et al.,. 1994; Evans,
Barer, & Marmor, 1994; Feinstein, 1993; Kaplan, 1996;
Kaplan et al., 1996; Kaplan & Keil, 1993; Kunst et al.,
1998; Lynch, Kaplan, & Salonen, 1997; Macintyre,
1986; McKeown & Lowe, 1974; Pappas et al., 1993;
Smith & Egger, 1992; Smith et al., 1998a) and even in
affluent countries with relatively equitable health care
provision (Black et al., 1980; Blane, Smith, & Bartley,
1990; Eachus et al., 1996; Mackenbach, Kunst, &
Cavelaars et al., 1997; Marmot et al., 1991; Townsend,
1990; Smith, Hart, Watt, Hole, & Hawthorne, 1998b).
Widening social inequalities in health should raise
concerns about the consequences of macroeconomic or
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P. Braveman, E. Tarimo I Social Science & Medicine 54 (2002) 1621-1635
social policy, not only about inequalities in health
services; while the health sector can play an important
role in documenting and disseminating evidence, action
by the health care sector alone may not be effective or
efficient. Equity in health care must be addressed,
because, while not the only determinant of health status,
health services are an important and often more easily
modifiable factor than some others (Egbuono & Star
field, 1982). However, advocates for equitable access to
health services must also be vocal advocates for
equitable distribution of other key determinants of
health, such as education, safe water and sanitation,
housing, and food security. Advocates for investment in
health care services may unwittingly play a destructive
role in the health outcomes of their societies, when such
investment competes with investment in other poten
tially more powerful determinants of health; this tension
is likely to be greatest in countries with the most limited
overall resources.
When developing strategies to increase equity, parti
cularly in low- and middle-income countries, it must be
• made clear that the goal is an equitable sharing of
progress in improving health, and not an equal
distribution of the health consequences of lack of
development; Whitehead has articulated the need to
“level up” rather than to “level down” (Whitehead,
1994). The | Primary Health Care strategy to achieve
Health for All, articulated and promoted by WHO from
the late 1970s on, was specifically designed to achieve
greater equity and overall progress in settings with
severe resource constraints. It entails a commitment to
universal coverage with (at least) the most effective
health services; that will disproportionately benefit
disadvantaged populations; reliance on low-technology,
community-based solutions; emphasis on education,
clean water, sanitation, and other living conditions
fundamental to health; as well as a commitment to
empowerment of those who have historically been
marginalized. This strategy is at least as relevant today
as it was two decades ago, when there was an
expectation of growing rather than shrinking resources
for social investment. There has been a notable silence at
WHO recently about Health for All and Primary Health
Care; this is unfortunate, creating the impression of
. stepping back from a commitment to equity, and should
be addressed by member countries. As part of reaffirm
ing the Health for All commitment, equity needs to
move from being largely implicit to becoming an explicit
component of the strategy, and progress toward greater
equity in health needs to be monitored systematically to
provide guidance for policy and programs at all levels.
Concerns about health equity in developing countries
cannot be adequately addressed with an exclusive focus
on closing north-south and between-country gaps.
Globally, with increasing market orientation on all
continents and in all political systems, there is a real risk
that concerns about equity will be forgotten—or paid
only token attention—on the policy agenda in the
pursuit of short-term gains reflected in average statistics.
It is of great importance to focus on equity in health, not
only because health status should be a key indicator of
human development, but also because in most societies,
there is less tolerance for avoidable disparities in health
than in wealth. Addressing health equity both requires
and provides an opening for addressing equity in the
determinants of health. At the beginning of the 21st
century, large segments of the population within nations
of very diverse per capita income levels remain on the
other side of a deep divide, enjoying little or no benefit
of the economic growth reflected in average national
economic indicators or even average health statistics.
Particularly in the context of an increasingly globalized
world, improvements in health for privileged groups
should suggest what could, with political will, be
possible for all.
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B
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8
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i
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‘i
If
j
i
ns
Orientation/Training Program on “Health as a
Human Right towards realizing Health for AH”
I
I
I
Session 3 Sharing of Experiences and its linkages to “Health
Community Health Cell, Bangalore
as Human Right”
Orientation/Training Program on “Health as a Human Right towards realizing Health for All”
I
Session 4 Understanding “Health As A Human Right” & Understanding Indian Constitutional
Rights & Health And Operational Mechanisms
Community Health Cell Bangalore
A PARADIGM SHIFT FROM 'CHARITY' TO 'RIGHTS AND DIGNITY'
- A write-up based „„ tbe United Nations Convention „„ ,be Rights „f Persons with Disabilities
(UNCRPD)
- C. Mahesh
I
faced by persons with disabilities to centre stage.
■mS a a
ISSU6S of dlscnminati°n and exclusion
h“
approach.
moved from being a merely
era e a Paradigm shift from ’charity' to 'rights based'
an
IS to promote, protect and ensure the
a -ve .bar has
firS*feW “““S “
’SXZ"SXSS1“„PZ» “aketa’y'ZS1'6
Z”"
"""
such as "Are you getting the freedom and cho^eto^^^
,finding S°1UtionS °n questions
society?", "Doesyour house/educational institution /nt ?
wante^at ^ome andin
access the toilehsafely/ independently? " "Are vo
‘t™ O^Wor^ ^ave Provisions to enable you to
1
gainful employment? " "Are vou ahh tn
Pt
i
own family?",
P
>
(countries) need to build on/ adopt
g
j
* ^re you Settl^g opportunitiesfor
e you being restrictedfrom setting-up your
°nitOnng mechanis™ ^at the state parties
Leprosy-cured, Hearing impimm"SoSteJdiSS MGal’S aS’
te
intellectual and who cannot get involved in societv hP
ViSi0”’
~ - ““
' ^ f^X^mp e' Physical’ psycho-social,
dtX“,,c and sensi,i"approachwith
among persons with
Organisations on the UNCRPD. There is also a need to develop appropriate strategies to review
existing laws, policies, programmes and monitoring mechanisms of Govt. Non-Government
Organisations and other agencies.
Further, this convention by design is not limited to only Govt, establishments. The Convention states
that private businesses and organizations that are open to the public parties have to take initiatives to
eliminate barriers that people with disabilities face in buildings, the outdoors, transport, information,
communication and services".
It is no longer enough to be content with providing a few "good willed" services such as a
"wheelchair" or a "hearing aid" or "disabilitypension" . It is going to be whether the laws, policies,
programmes and schemes are in line and reinforce the principles of the Convention that focus on
Dignity, Ability to choose, Independence, Non-discrimination, Participation, Full inclusion, Respect
for difference, Acceptance of disability as part of everyday life, Equality of opportunity, Accessibility,
Equality of men and women and Respect for children.
By signing and ratifying this Convention, it is now legally binding on India and other countries of the
UN to create and promote an environment where persons with disabilities are able to exercise their
civil, political, social and cultural rights fairly and without prejudice.
It is time that Govt, representatives, representatives from Disabled People's Organisations, NGOs and
other stake holders sit together and chalk out precise strategies as operation plan to take the
Convention forward. If this is not done the Convention will be just another book on the shelf.
Finally, this Convention is about creating a society that recognizes and respects the diverse needs of
humankind.
References:
1. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) is at
http://www.un.org/disabilities/
2. The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)
Act is at http://ccdisabilities.nic.in/
About the author:
I
C. Mahesh works for CBR Forum, as the Advocacy Coordinator in promoting the rights ofpersons
with disabilities through supporting 87 of their community based rehabilitation programmes across the
country. In addition he is actively involved with the Office of the Commissioner (Disabilities)
Karnataka and other networks in promoting 'barrier-free' environment and advocatingfor the effective
implementationof The Persons with Disabilities (Equal Opportunities, Protection ofRights and Full
Participation) Act.
C. Mahesh
Advocacy Coordinator
CBR Forum
14, CK Garden, Wheeler Road Extension, Bangalore - 560 084
Tel - +91 - 80- 2549 7387 or 2549 7388
advocacy.cbrforum@gmail.com or cbrforum@gmail.com
www.cbrforum.in
I
A.
THE INTERNATIONAL BILL OF
HUMAN RIGHTS
i.
Universal Declaration of Human Rights
Adopted and proclaimed by General Assembly resolution 217 A (III)
of 10 December 1948
7
Preamble
• , . ^erfas recognition of the inherent dignity and of the equal and inalienable
peace Fnthe woj" °f
*the f°Undation of ^domJustice and
^eJeifS dlsreSard ,and contempt for human rights have resulted in barbarous
acts which have outraged the conscience of mankind, and the advent of a world in
which human beings shall enjoy freedom of speech and belief and freedom from
fear and want has been proclaimed as the highest aspiration of the common people,
,
it is essential, if man is not to be compelled to have recourse as a last
tected by ittfeonaw,5*0PPreSSi°n’‘hathUmanrightSSh°U1‘1 beproWhereas it is essential to promote the development of friendly relations
between nations,
'
■ Whf'efS the P,e°P'eS °f the United Nations have in the Charter reaffirmed their
: fn the"laull3 HpHu hf man ri8lLtS’ 'n the dignity and worth of the human P^on and
in the equal rights of men and women and have determined to promote social
progress and better standards of life in larger freedom,
P
’
with t^XMMnlber St.utes have pledged themselves to achieve, in co-operation
: human“d
therefore,
The General Assembly,
I
nf
Vniver?aI DeJc,arati0n of Human Rights as a common standard
of achievement for all peoples and all nations, to the end that every individual and
very organ of society, keeping this Declaration constantly in mind, shall strive by
I
j
1
The International Bill of Human Rights_______________________
2
recognition and observance, both among the peoples of Member States themselves
and among the peoples of territories under their jurisdiction.
Article 1
I
I
Igs arc
bull! free and equal in dignity and rights. They are
All human beings
are born
and
conscience and should act towards one another in a spirit
endowed with reason a.
-----------of brotherhood.
Article 2
Everyone is entitled to all the rights and freedoms set forth inthis Declar^l°"’
without distinction of any kind, such as race, colour, sex language, religion, pol
cal or other opinion, national or social origin, property, birth or other status.
Furthermore, no distinction shall be made on the basis of the political, juris- f
dictional or international status of the country or territory to which a[ Perf.on.^el°^’ :
whether it be independent, trust, non-self-governing or under any other limitation o
sovereignty.
Article 3
Everyone has the right to life, liberty and security of person.
Article 4
No one shall be held in slavery or servitude; slavery and the slave trade shall
be prohibited in all their forms.
Article 5
No one shall be subjected to torture or to cruel, inhuman or degrading treat
ment or punishment.
Article 6
Everyone has the right to recognition everywhere as a person before the law.
Article 7
All are equal before the law and are entitled without any discrimination to
equal protection of the law. All are entitled to equal protection against any discrim
ination in violation of this Declaration and against any incitement to such discrimi
nation.
Article 8
Everyone has the right to an effective remedy by the competent national tribu
nals for acts violating the fundamental rights granted him by the constitution or by
law.
I
I
I ■
Universal Declaration of Human Rights
3
Article 9
No one shall be subjected to arbitrary arrest, detention or exile.
Article 10
Everyone is entitled in full equality to a fair and public hearing by an indepen
dent and impartial tribunal, in the determination of his rights and obligations and of
any criminal charge against him.
Article 11
1. Everyone charged with a penal offence has the right to be presumed inno
cent until proved guilty according to law in a public trial at which he has had all the
guarantees necessary for his defence.
2. No one shall be held guilty of any penal offence on account of any act or
omission which did not constitute a penal offence, under national or international
law, at the time when it was committed. Nor shall a heavier penalty be imposed than
the one that was applicable at the time the penal offence was committed.
Article 12
No one shall be subjected to arbitrary interference with his privacy, family,
home or correspondence, nor to attacks upon his honour and reputation. Everyone
has the right to the protection of the law against such interference or attacks.
Article 13
1. Everyone has the right to freedom of movement and residence within the
borders of each State.
2. Everyone has the right to leave any country, including his own, and to
return to his country.
Article 14
1. Everyone has the right to seek and to enjoy in other countries asylum from
persecution.
f
2. This right may not be invoked in the case of prosecutions genuinely aristhg U°m j0^"P.0,itical crimes or from acts contrary to the purposes and principles of
Article 15
1.
Everyone has the right to a nationality.
2. No one shall be arbitrarily deprived of his nationality nor denied the right
to change his nationality.
111
4
The International Bill of Human Rights
Article 16
1. Men and women of full age, without any limitation due to race, national
ity or religion, have the right to marry and to found a family. They are entitled to
equal rights as to marriage, during marriage and at its dissolution.
2. Marriage shall be entered into only with the free and full consent of the
intending spouses.
3. The family is the natural and fundamental group unit of society and is
entitled to protection by society and the State.
Article 17
i
I
1. Everyone has the right to own property alone as well as in association
with others.
2.
No one shall be arbitrarily deprived of his property.
Article 18
Everyone has the right to freedom of thought, conscience and religion; this
right includes freedom to change his religion or belief, and freedom, either alone or
in community with others and in public or private, to manifest his religion or belief
in teaching, practice, worship and observance.
Article 19
Everyone has the right to freedom of opinion and expression; this right
includes freedom to hold opinions without interference and to seek, receive and
impart information and ideas through any media and regardless of frontiers.
Article 20
1.
Everyone has the right to freedom of peaceful assembly and association.
2.
No one may be compelled to belong to an association.
1.
r
•
■ right
________
Everyone
has
the
to take part in the government of his country,
Article 21
directly or through freely chosen representatives.
2.
Everyone has the right to equal access to public service in his country.
♦uthe people shall be the basis of the authority of governmentthis will shall be expressed in periodic and genuine elections which shall be by uniing^rocedureT SUffrage and sha11 be held by secret vote or by equivalent free vot-
I
Article 22
Everyone, as a member of society, has the right to social security and is enti
tled to realization, through national effort and international co-operation and in
accordance with the organization and resources of each State, of the economic,
\l<4
1I
------------ --------------------- Universal Declaration of Human Rights
h?sCpersonality3'
<«gW and the free development of
indisPensab,e for
I •
5
Article 23
'
work.2'
Every°ne’ Without
discrimination, has the right to equal pay for equal
remuneration
1
'• of h,SmtereZ°ne
t0 j°in trade unions
t0
‘he protection
Article 24
%
Article 25
!
teal care and necessary social services, and the right to security in the event of unem
cumsZces'bSond hisacontrordOWh00d’
" °ther
of livelihood in cir.i -u 2' hdotherhood and childhood are entitled to special care and assistance All
chtldren, whether born tn or out of wedlock, shall enjoy the same "ocSlpXction
Article 26
element Every°ne has the right
I
education. Education shall be free, at least in the
education shall be equally accessible to all on the basis of merit.
g
ait 2'a tEd+ulcat,on sh^1 b.e directed to the full development of the human nersonahty and to the strengthening of respect for human rights and fundamental freesh1aI,.promote understanding, tolerance and friendship among all nations
the minten^ceofS
Sha"
aC,iVi‘ieS °f
UnitedNati°nS
given to ^1^^ '
^b't0 Cb°0Se the kind °f education ‘ha‘ ^11 be
Article 27
mimiJ,’ fnEVery°+ue hiS the JriShtifreely t0 participate in the cultural life of the comunity, to enjoy the arts and to share in scientific advancement and its benefits.
I
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The International Bill of Human Rights
rAcuif2' fEveryone has the right to the protection of the moral and material interests
suiting from any scientific, literary or artistic production of which he is the author.
I
Article 28
tadSSSIffKXSSSj'SS'** rlEl”! “d
Article 29
fr” “d “
recognition and respect for the rights and freedoms of others and of meeting the iust
requirements of morality, public order and the general welfare in a democratic sici3. These rights and freedoms may in no case be exercised contrary to the
purposes and principles of the United Nations.
Article 30
Nothing in this Declaration may be interpreted as implying for anv Stat?
I
*!
(
2.
International Covenant on Economic, Social and Cultural Rights
Adopted and openedfor signature, ratification and accession by General Assembly resolution
2200 A (XXI) of 16 December 1966
Entry into force: 3 January 1976, in accordance with article 27
I.
Preamble
The States Parties to the present Covenant,
Considering that, in accordance with the principles proclaimed in the Charter
of the United Nations, recognition of the inherent dignity and of the equal and
inalienable rights of all members of the human family is the foundation of freedom
justice and peace in the world,
Recognizing that these rights derive from the inherent dignity of the human
person,
Recognizing that, in accordance with the Universal Declaration of Human
Rights, the ideal of free human beings enjoying freedom from fear and want can
only be achieved if conditions are created whereby everyone may enjoy his eco
nomic, social and cultural rights, as well as his civil and political rights,
Considering the obligation of States under the Charter of the United Nations
to promote universal respect for, and observance of, human rights and freedoms,
Realizing that the individual, having duties to other individuals and to the
community to which he belongs, is under a responsibility to strive for the promotion
and observance of the rights recognized in the present Covenant,
Agree upon the following articles:
Part I
Article 1
1. All peoples have the right of self-determination. By virtue of that right
they freely determine their political status and freely pursue their economic, social
and cultural development.
I
2. All peoples may, for their own ends, freely dispose of their natural wealth
and resources without prejudice to any obligations arising out of international eco
nomic co-operation, based upon the principle of mutual benefit, and international
law. In no case may a people be deprived of its own means of subsistence.
7
IV?
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The International Bill of lluiium Rights
3. The States Parties to the present Covenant, including those having respon
sibility for the administration of Non-Self-Governing and Trust Territories, shall
promote the realization of the right of self-determination, and shall respect that
right, in conformity with the provisions of the Charter of the United Nations.
Part II
Article 2
1. Each State Party to the present Covenant undertakes to take steps, indi
vidually and through international assistance and co-operation, especially economic
and technical, to the maximum of its available resources, with a view to achieving
progressively the full realization of the rights recognized in the present Covenant by
all appropriate means, including particularly the adoption of legislative measures.
2. The States Parties to the present Covenant undertake to guarantee that the
rights enunciated in the present Covenant will be exercised without discrimination
of any kind as to race, colour, sex, language, religion, political or other opinion,
national or social origin, property, birth or other status.
3. Developing countries, with due regard to human rights and their national
economy, may determine to what extent they would guarantee the economic rights
recognized in the present Covenant to non-nationals.
Article 3
The States Parties to the present Covenant undertake to ensure the equal right
of men and women to the enjoyment of all economic, social and cultural rights set
forth in the present Covenant.
Article 4
The States Parties to the present Covenant recognize that, in the enjoyment of
those rights provided by the State in conformity with the present Covenant, the State
may subject such rights only to such limitations as are determined by law only in so
far as this may be compatible with the nature of these rights and solely for the pur
pose of promoting the general welfare in a democratic society.
I
Article 5
1. Nothing in the present Covenant may be interpreted as implying for any
State, group or person any right to engage in any activity or to perform any act aimed
at the destruction of any of the rights or freedoms recognized herein, or at their lim
itation to a greater extent than is provided for in the present Covenant.
2. No restriction upon or derogation from any of the fundamental human
rights recognized or existing in any country in virtue of law, conventions, regula
tions or custom shall be admitted on the pretext that the present Covenant does not
recognize such rights or that it recognizes them to a lesser extent.
III
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International Covenant on Economic, Social and Cultural Rights
9
Part III
Article 6
which he freely chooses or accepts, and will take appropriate steps to safeguard this
th r u The S-tepS !°,be taken by a State Par,yt0 the Present Covenant to achieve
the full reahzahon of this right shall include technical and vocational guidance and
training programmes, policies and techniques to achieve steady economic social
Lio" T1 dfeve'°Pmen! an,d
and productive employment unde? conditions
safeguarding fundamental political and economic freedoms to the individual.
Article 7
The States Parties to the present Covenant recognize the right of everyone to
the enjoyment ofjust and favourable conditions of work which ensure, in particular:
(a) Remuneration which provides all workers, as a minimum, with:
I
(i) Fair wages and equal remuneration for work of equal value without disk,?d’u,n part,.cular women being guaranteed conditions of
work not inferior to those enjoyed by men, with equal pay for equal work;
(ii) A decent living for themselves and their families in accordance with the
provisions of the present Covenant;
(7>) Safe and healthy working conditions;
a.y. 'ASS'S
1.
isg?
”d
“■
Article 8
The States Parties to the present Covenant undertake to ensure:
(a) The right of everyone to form trade unions and join the trade union of his
and nmrSUreCt
t0 the rU eS °f the or8anization concerned, for the promotion
and protection of his economic and social interests. No restrictions maybe placed
°
exer'jlse of this right other than those prescribed by law and which are necfn^'n.3 democrat,u solely m the interests of national security or public order or
for the protection of the rights and freedoms of others;
tinn« nA)d Th'16
tions- d he
0/UnionS t0 estabIish national federations or confedera
°f the attert0 form or j°in international trade-union organiza-
fhan fhnLThe
“"'T5 function free|y subject to no limitations other
han those prescribed by law and which are necessary in a democratic society in the
in
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The International Bill of Human Rights
!
interests of national security or public order
freedoms of,~
“ PUb‘iC °rder °r f°r the Pr0tection
rights and
iawso(^ihp:;i±oc:turS;.provided that il is exercised in conformity with *
zSSB—»»»
Article 9
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Article 10
The States Parties to the present Covenant recognize that:
familv1 whTrhk ^estPoss*ble P^ecticn and assistance should be accorded to the
Article 11
ass=s===gg
right of evIryon^beTre:^^^
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International Covenant on Economic, Social and Cultural Rights
11
national co-operation, the measures, including specific programmes, which are
needed:
(a) To improve methods of production, conservation and distribution of food
by making full use of technical and scientific knowledge, by disseminating know
ledge of the principles of nutrition and by developing or reforming agrarian systems
in such a way as to achieve the most efficient development and utilization of natural
resources;
(Zj) Taking into account the problems of both food-importing and food
exporting countries, to ensure an equitable distribution of world food supplies in
relation to need.
Article 12
1. The States Parties to the present Covenant recognize the right of everyone
to the enjoyment of the highest attainable standard of physical and mental health.
I
2. The steps to be taken by the States Parties to the present Covenant to
achieve the full realization of this right shall include those necessary for:
(a) The provision for the reduction of the stillbirth-rate and of infant mortality
and for the healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational
and other diseases;
(d) The creation of conditions which would assure to all medical service and
medical attention in the event of sickness.
i
Article 13
i
1. The States Parties to the present Covenant recognize the right of everyone
to education. They agree that education shall be directed to the full development of
the human personality and the sense of its dignity, and shall strengthen the respect
for human rights and fundamental freedoms. They further agree that education shall
enable all persons to participate effectively in a free society, promote understanding,
tolerance and friendship among all nations and all racial, ethnic or religious groups,
and further the activities of the United Nations for the maintenance of peace.
I
2. The States Parties to the present Covenant recognize that, with a view to
achieving the full realization of this right:
I,
1
(a) Primary education shall be compulsory and available free to all;
(6) Secondary education in its different forms, including technical and voca
tional secondary education, shall be made generally available and accessible to all
by every appropriate means, and in particular by the progressive introduction of free
education;
111
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12
The International Bill of Human Rights
(c) Higher education shall be made equally accessible to all, on the basis of
capacity, by every appropriate means, and in particular by the progressive introduc
tion of free education;
(t/) Fundamental education shall be encouraged or intensified as far as possi
ble for those persons who have not received or completed the whole period of their
primary education;
‘f
(e) The development of a system of schools at all levels shall be actively pur
sued, an adequate fellowship system shall be established, and the material condi
tions of teaching staff shall be continuously improved.
i t?’
States Parties to the present Covenant undertake to have respect for
the liberty of parents and, when applicable, legal guardians to choose for their chil
dren schools, other than those established by the public authorities, which conform
to such minimum educational standards as may be laid down or approved by the
State and to ensure the religious and moral education of their children in conformity
with their own convictions.
‘
r•
part °f thi? article shaI1 be construed so as to interfere with the liberty
o individuals and bodies to establish and direct educational institutions, subject
always to the observance of the principles set forth in paragraph 1 of this article and
to the requirement that the education given in such institutions shall conform to such
minimum standards as may be laid down by the State.
Article 14
Each State Party to the present Covenant which, at the time of becoming a
Farty, has not been able to secure in its metropolitan territory or other territories
under its jurisdiction compulsory primary education, free of charge, undertakes
within two years, to work out and adopt a detailed plan of action for the progressive
implementation, within a reasonable number of years, to be fixed in the plan, of the
principle of compulsory education free of charge for all.
Article 15
1.
one:
The States Parties to the present Covenant recognize the right of every-
(a) To take part in cultural life;
(b) To enjoy the benefits of scientific progress and its applications;
vation, the development and the diffusion of science and culture.
3. The States Parties to the present Covenant undertake to respect the free
dom indispensable for scientific research and creative activity.
1
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International Covenant on Economic, Social and Cultural Rights
13
4. The States Parties to the present Covenant recognize the benefits to be
derived from the encouragement and development of international contacts and co
operation in the scientific and cultural fields.
Part IV
Article 16
1. The States Parties to the present Covenant undertake to submit in confor
mity with this part of the Covenant reports on the measures which they have adopted
and the progress made in achieving the observance of the rights recognized herein.
i
2. (a) All reports shall be submitted to the Secretary-General of the United
Nations, who shall transmit copies to the Economic and Social Council for consid
eration in accordance with the provisions of the present Covenant;
(6) The Secretary-General of the United Nations shall also transmit to the
specialized agencies copies of the reports, or any relevant parts therefrom, from
States Parties to the present Covenant which are also members of these specialized
agencies in so far as these reports, or parts therefrom, relate to any matters which
fall within the responsibilities of the said agencies in accordance with their consti
tutional instruments.
Article 17
1. The States Parties to the present Covenant shall furnish their reports in
stages, in accordance with a programme to be established by the Economic and
• Social Council within one year of the entry into force of the present Covenant after
consultation with the States Parties and the specialized agencies concerned.
I
2. Reports may indicate factors and difficulties affecting the degree of ful
filment of obligations under the present Covenant.
3. Where relevant information has previously been furnished to the United
Nations or to any specialized agency by any State Party to the present Covenant, it
will not be necessary to reproduce that information, but a precise reference to the
information so furnished will suffice.
I
Article 18
I,
Pursuant to its responsibilities under the Charter of the United Nations in the
field of human rights and fundamental freedoms, the Economic and Social Council
may make arrangements with the specialized agencies in respect of their reporting
to it on the progress made in achieving the observance of the provisions of the
present Covenant falling within the scope of their activities. These reports may
include particulars of decisions and recommendations on such implementation
adopted by their competent organs.
Article 19
The Economic and Social Council may transmit to the Commission on Human
Rights for study and general recommendation or, as appropriate, for information the
I
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14
The International Bill of Human Rights
reports concerning human rights submitted by States in accordance with articles-16
and 17, and those concerning human rights submitted by the specialized agencies in
accordance with article 18.
Article 20
The States Parties to the present Covenant and the specialized agencies con
cerned may submit comments to the Economic and Social Council on any general
recommendation under article 19 or reference to such general recommendation in
any report of the Commission on Human Rights or any documentation referred to
therein.
Article 21
I
The Economic and Social Council may submit from time to time to the Gen
eral Assembly reports with recommendations of a general nature and a summary of
the information received from the States Parties to the present Covenant and the spe
cialized agencies on the measures taken and the progress made in achieving general
observance of the rights recognized in the present Covenant.
Article 22
I
The Economic and Social Council may bring to the attention of other organs
° • uT
Nations, their subsidiary organs and specialized agencies concerned
with furnishing technical assistance any matters arising out of the reports referred to
m this part of the present Covenant which may assist such bodies in deciding, each
within its field of competence, on the advisability of international measures likely
to contribute to the effective progressive implementation of the present Covenant.
Article 23
The States Parties to the present Covenant agree that international action for
the achievement of the rights recognized in the present Covenant includes such
methods as the conclusion of conventions, the adoption of recommendations, the
furnishing of technical assistance and the holding of regional meetings and technical
meetings for the purpose of consultation and study organized in conjunction with
the Governments concerned.
Article 24
Nothing in the present Covenant shall be interpreted as impairing the provi
sions of the Charter of the United Nations and of the constitutions of the specialized
agencies which define the respective responsibilities of the various organs of the
United Nations and of the specialized agencies in regard to the matters dealt with in
the present Covenant.
Article 25
• u* Nothing in the present Covenant shall be interpreted as impairing the inherent
resources PeoP es t0 enj°y anc^ ut’^ze fully and freely their natural wealth and
■f
International Covenant on Economic, Social and Cultural Rights
15
PartV
,
.1
Article 26
J. The present Covenant is open for signature by any State Member of the
United Nations or member of any of its specialized agencies, by any State Party to
the Statute of the International Court of Justice, and by any other State which has
been invited by the General Assembly of the United Nations to become a party to
the present Covenant.
,
2. The present Covenant is subject to ratification. Instruments of ratification
! shall be deposited with the Secretary-General of the United Nations.
3. The present Covenant shall be open to accession by any State referred to
in paragraph 1 of this article.
4. Accession shall be effected by the deposit of an instrument of accession
: with the Secretary-General of the United Nations.
J.
5. The Secretary-General of the United Nations shall inform all States which
have signed the present Covenant or acceded to it of the deposit of each instrument
of ratification, or accession.
Article 27
1. The present Covenant shall enter into force three months after the date of
the deposit with the Secretary-General of the United Nations of the thirty-fifth
instrument of ratification or instrument of accession.
2. For each State ratifying the present Covenant or acceding to it after the
deposit of the thirty-fifth instrument of ratification or instrument of accession, the
present Covenant shall enter into force three months after the date of the deposit of
its own instrument of ratification or instrument of accession.
. I
Article 28
The provisions of the present Covenant shall extend to all parts of federal
States without any limitations or exceptions.
Article 29
1. Any State Party to the present Covenant may propose an amendment and
file it with the Secretary-General of the United Nations. The Secretary-General shall
thereupon communicate any proposed amendments to the States Parties to the
present Covenant with a request that they notify him whether they favour a confer
ence of States Parties for the purpose of considering and voting upon the proposals.
In the event that at least one third of the States Parties favours such a conference,
the Secretary-General shall convene the conference under the auspices of the United
Nations. Any amendment adopted by a majority of the States Parties present and
voting at the conference shall be submitted to the General Assembly of the United
Nations for approval.
2. Amendments shall come into force when they have been approved by the
General Assembly of the United Nations and accepted by a two-thirds majority of
i
16
The International Bill of Human Rights
s^udonal Jracess^sthe
C°Venant
aCC0rdance with their respective con-
amendments come into force they shall be binding on those States
Parties which have accepted them, other States Parties still being bound by the proa‘S‘0".Sdof the present Covenant and any earlier amendment which they have
aCucpiCO.
J
Article 30
(a) Signatures, ratifications and accessions under article 26;
and the^da^ofthe
T? int° c"06 °f the preSent Covel’ant under article 27
and the date of the entry into force of any amendments under article 29.
Article 31
j q1’
Present Covenant, of which the Chinese, English, French, Russian
UnitedPNa^nnsXtS
eqUally aUthen
‘iC’ Sha
dePosited in the archives of the
equally
authentic,
shall" be deposited
kJiiiivU INaliOliS.
«.r SS22S S, XXSS “m““pi
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a
and
Public
Health
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General Comment No. 14:
The right to the highest
‘ attainable standard of health
Committee on Economic,
Social, and Cultural Rights
Twenty-second session
25 April-12 May 2000
Geneva
•
Copyright 2002 Lawrence O. Gostin. No claim made to original government works
i
Doc. 4004
UNITED
NATIONS
E
I
Distr.
general
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E/C. 12/2000/4,
CESCR General
comment 14
July 2000
_____
""
Original: ENGLISH
I
Th^oo^
Convention Abbreviation: CESCR
COMMITTEE ON ECONOMIC
and cultural rights
Twenty-second session
Geneva, 25 April-12 May 2000
Agenda item 3
SOCIAL
S^raJ-Coniment No. 14 (2000)
'aauioiXs^^
------
—^Social and Cultural RiHitat
rights. Every humtnTdng ^entkled to i'SpenSabIe for the zeroise of other human
of health conducive to living a life in digi ky^TheTf
h'/heSt attainable s^ndard
pursued through numerous, complementary aonroaeh^
u
right t0 hea,th may be
policies, or the implementation of health nrn PP
heS’ SUCh aS tbe fo.rmulation of health
(WHO). „ ,he XLby ,h'
includes certain components which are legaHy eXXTf h"'0''"' "" "fh'to
i
i
25.1 of the™ nirereal0Declaration o°f H
standard of living adeou,te
'"t."™0"’ '""™lional instruments. Article
^r^rofbi^ffaS^h^'^” h’S
ri81" “ »
ciothing. housing and medical care .ndX^e”?^^
12.1 of the Covenant, States parties recognize^’the" rig.htS law'In accordance with article
’d" n r'i""'"'’ °f AI1
Forms of Racial Discrimination oi%5 i„
16) and the Additional Protoetno theSmer “n CoT r
Of 198’ <a^
Area of Economic. Social and Cultural Rights of MsClOt" cTi RiShts
health has been proclaimed bv the f'nmm;
>, ( ' 0)' Slnil,ar|y- ‘he right to
Vienna Deciar.tion .X^mme of Z„ o“l’ 3™d T"
" *'
instruments. (3)
f 993 d other lnte™ational
hum^HXXXX^^
housing, work, education human diankv Hf
°f R gh‘s> mcludmg the rights to food,
I
Constitution of WHO, which conceoS.ze h
I
in the preamb,e t0 the
Zeve“1h“efL”oemna8n,“ed STX
I
SSBES=S^==S‘
ssssssis
international and other factors beyond the control of States that impede the full
realization of article 12 in many States parties.
6. With a view to assisting States parties' implementation of the Covenant and the
fulfilment of their reporting obligations, this General Comment focuses on the normative
content of article 12 (Part I), States parties' obligations (Part II), violations (Part III) and
implementation at the national level (Part IV), while the obligations of actors other than
States parties are addressed in Part V. The General Comment is based on the Committee's
experience in examining States parties' reports over many years.
I. NORMATIVE CONTENT OF ARTICLE 12
7. Article 12.1 provides a definition of the right to health, while article 12.2 enumerates
illustrative, non-exhaustive examples of States parties' obligations.
8. The right to health is.not to be understood as a right to be healthy. The right to health
contains both freedoms and entitlements. The freedoms include the right to control one's
health and body, including sexual and reproductive freedom, and the right to be free from
interference, such as the right to be free from torture, non-consensual medical treatment
and experimentation. By contrast, the entitlements include the right to a system of health
protection which provides equality of opportunity for people to enjoy the highest
attainable level of health.
9. The notion of "the highest attainable standard of health" in article 12.1 takes into
account both the individual's biological and socio-economic preconditions and a State's
available resources. There are a number of aspects which cannot be addressed solely
within the relationship between States and individuals; in particular, good health cannot
be ensured by a State, nor can States provide protection against every possible cause of
human ill health. Thus, genetic factors, individual susceptibility to ill health and the
adoption of unhealthy or risky lifestyles may play an important role with respect to an
individual's health. Consequently, the right to health must be understood as a right to the
enjoyment of a variety of facilities, goods, services and conditions necessary for the
realization of the highest attainable standard of health.
10. Since the adoption of the two International Covenants in 1966 the world health
situation has changed dramatically and the notion of health has undergone substantial
changes and has also widened in scope. More determinants of health are being taken into
consideration, such as resource distribution and gender differences. A wider definition of
health also takes into account such socially-related concerns as violence and armed
conflict. (4) Moreover, formerly unknown diseases, such as Human Immunodeficiency
Virus and Acquired Immunodeficiency Syndrome (HI V/AIDS), and others that have
become more widespread, such as cancer, as well as the rapid growth of the world
population, have created new obstacles for the realization of the right to health which
need to be taken into account when interpreting article 12.
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11. The Committee interprets the right to health, as defined in article 12.1, as an inclusive
right extending not only to timely and appropriate health care but also to the underlying
determinants of health, such as access to safe and potable water and adequate sanitation,
an adequate supply of safe food, nutrition and housing, healthy occupational and
environmental conditions, and access to health-related education and information,
including on sexual and reproductive health. A further important aspect is the
participation of the population in all health-related decision-making at the community,
national and international levels.
12. The right to health in all its forms and at all levels contains the following interrelated
and essential elements, the precise application of which will depend on the conditions
prevailing in a particular State party:
(a) Availability. Functioning public health and health-care facilities, goods and services,
as well as programmes, have to be available in sufficient quantity within the State party.
The precise nature of the facilities, goods and services will vary depending on numerous
factors, including the State party's developmental level. They will include, however, the
underlying determinants of health, such as safe and potable drinking water and adequate
sanitation facilities, hospitals, clinics and other health-related buildings, trained medical
and professional personnel receiving domestically competitive salaries, and essential
drugs, as defined by the WHO Action Programme on Essential Drugs. (5)
(^Accessibility. Health facilities, goods and services (6) have to be accessible to
everyone without discrimination, within the jurisdiction of the State party. Accessibility
has four overlapping dimensions:
Non-discrimination: health facilities, goods and services must be accessible to all,
especially the most vulnerable or marginalized sections ol the population, m law and in
fact, without discrimination on any of the prohibited grounds. (7)
Physical accessibility: health facilities, goods and services must be within safe physical
reach for all sections of the population, especially vulnerable or marginalized groups,
such as ethnic minorities and indigenous populations, women, children, adolescents,
older persons, persons with disabilities and persons with HIV/AIDS. Accessibility also
implies that medical services and underlying determinants of health, such as safe and
potable water and adequate sanitation facilities, are within safe physical reach, including
in rural areas. Accessibility further includes adequate access to buildings for persons with
disabilities.
Economic accessibility (affordability): health facilities, goods and services must be
affordable for all. Payment for health-care services, as well as services related to the
underlying determinants of health, has to be based on the principle of equity, ensuring
that these services, whether privately or publicly provided, are affordable for a l
including socially disadvantaged groups. Equity demands that poorer households should
not be disproportionately burdened with health expenses as compared to richer
households.
I
Information accessibility: accessibility includes the right to seek, receive and impart
information and ideas (8) concerning health issues. However, accessibility of information
should not impair the right to have personal health data treated with confidentiality.
(^Acceptability. All health facilities, goods and services must be respectful of medical
ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities,
peoples and communities, sensitive to gender and life-cycle requirements, as well as
being designed to respect confidentiality and improve the health status of those
concerned.
(d) Quality. As well as being culturally acceptable, health facilities, goods and services
must also be scientifically and medically appropriate and of good quality. This requires,
inter alia, skilled medical personnel, scientifically approved and unexpired drugs and
hospital equipment, safe and potable water, and adequate sanitation.
13. The non-exhaustive catalogue of examples in article 12.2 provides guidance in
defining the action to be taken by States. It gives specific generic examples of measures
arising fiom the broad definition of the right to health contained in article 12.1, thereby
illustrating the content of that right, as exemplified in the following paragraphs. (9)
—1 tide 12.2 (a). The right to maternal, child and reproductive health
14. "The provision for the reduction of the stillbirth rate and of infant mortality and for
the healthy development of the child" (art. 12.2 (a)) (10) may be understood as requiring
measures to improve child and maternal health, sexual and reproductive health services,
including access to family planning, pre- and post-natal care, (II) emergency obstetric
services and access to information, as well as to resources necessary to act on that
information. (12)
Article 12.2 (b). The right to healthy natural and workplace environrnents
15. 1 he improvement ol all aspects of environmental and industrial hygiene" (art. 12.2
(b)) comprises, inter alia, preventive measures in respect of occupational accidents and
diseases; the requirement to ensure an adequate supply of safe and potable water and
basic sanitation; the prevention and reduction of the population's exposure to harmful
substances such as radiation and harmful chemicals or other detrimental environmental
conditions that directly or indirectly impact upon human health. (13) Furthermore,
industrial hygiene refers to the minimization, so far as is reasonably practicable, of the
causes of health hazards inherent in the working environment. (14) Article 12.2 (b) also
embraces adequate housing and safe and hygienic working conditions, an adequate
supply of food and proper nutrition, and discourages the abuse of alcohol, and the use of
tobacco, drugs and other harmful substances.
Article 12.2 (c). The right to prevention, treatment and control of diseases
.
e prevention, treatment and control of epidemic, endemic, occupational and other
diseases (art 12.2 (c)) requires the establishment of prevention and education
programmes for behaviour-related health concerns such as sexually transmitted diseases
in particular HIV/AIDS, and those adversely affecting sexual and reproducXe heZ
ano the promotion of social determinants of good health, such as environmental safety
education economic development and gender equity. The right to treatment includes the
creation of a system of urgent medical care in cases of accidents, epidemics and similar
health hazards, and the provision of disaster relief and humanitarian assistance in
emergency situations. The control of diseases refers to States' individual and joint efforts
to, inter aha, make available relevant technologies, using and improving epidemiological
surveillance and data collection on a disaggregated basis, the implementation or
enhancement of immunization programmes and other strategies of infectious disease
control.
Article 12.2 (d). The right to health facilities, goods and services (15)
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17. The creation of conditions which would assure to all medical service and medical
attention in the event of sickness" (art. 12.2 (d)), both physical and mental, includes the
provision of equal and timely access to basic preventive, curative, rehabilitative health
services and health education; regular screening programmes; appropriate treatment of
prevalent diseases, illnesses, injuries and disabilities, preferably at community level; the
provision of essential drugs; and appropriate mental health treatment and care. A further
important aspect is the improvement and furtherance of participation of the population in
the provision of preventive and curative health services, such as the organization of the
health sector, the insurance system and, in particular, participation in political decisions
relating to the right to health taken at both the community and national levels
Article 12. Special topics of broad application
'
Non-discrimination and equal treatment
18. By virtue of article 2.2 and article 3, the Covenant proscribes any discrimination in
access to health care and underlying detenninants of health, as well as to means and
entitlements for their procurement, on the grounds of race, colour, sex, language, religion,
political or other opinion, national or social origin, property, birth, physical or mental
disability, health status (including HIV/AIDS), sexual orientation and civil, political
social or other status, which has the intention or effect of nullifying or impairing the'
equal enjoyment or exercise of the right to health. The Committee stresses that many
measures, such as most strategies and programmes designed to eliminate health-related
discrimination, can be pursued with minimum resource implications through the
adoption, modification or abrogation of legislation or the dissemination of information.
The Committee recalls General Comment No. 3, paragraph 12, which states that even in
times of severe resource constraints, the vulnerable members of society must be protected
by the adoption of relatively low-cost targeted programmes.
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19. With respect to the right to health, equality of access to health care and health
services has to be emphasized. States have a special obligation to provide those who do
not have sufficient means with the necessary health insurance and health-care facilities,
and to prevent any discrimination on internationally prohibited grounds in the provision
of health care and health services, especially with respect to the core obligations of the
right to health. (16) Inappropriate health resource allocation can lead to discrimination
that may not be overt. For example, investments should not disproportionately favour
expensive curative health services which are often accessible only to a small, privileged
fraction of the population, rather than primary and preventive health care benefiting a far
larger part of the population.
Gender perspective
20. The Committee recommends that States integrate a gender perspective in their healthrelated policies, planning, programmes and research in order to promote better health for
both women and men. A gender-based approach recognizes that biological and socio
cultural factors play a significant role in influencing the health of men and women. The
disaggregation of health and socio-economic data according to sex is essential for
identifying and remedying inequalities in health.
Women and the right to health
21. To eliminate discrimination against women, there is a need to develop and implement
a comprehensive national strategy for promoting women's right to health throughout their
life span. Such a strategy should include interventions aimed at the prevention and
treatment of diseases affecting women, as well as policies to provide access to a full
range of high quality and affordable health care, including sexual and reproductive
services. A major goal should be reducing women's health risks, particularly lowering
rates of maternal mortality and protecting women from domestic violence. The
realization of women's right to health requires the removal of all barriers interfering with
access to health services, education and information, including in the area of sexual and
reproductive health. It is also important to undertake preventive, promotive and remedial
action to shield women from the impact of harmful traditional cultural practices and
norms that deny them their full reproductive rights.
Children and adolescents
22. Article 12.2 (a) outlines the need to take measures to reduce infant mortality anjd
promote the healthy development of infants and children. Subsequent international •
human rights instruments recognize that children and adolescents have the right to the
enjoyment of the highest standard of health and access to facilities for the treatment of
illness. (17)
The Convention on the Rights of the Child directs States to ensure access to essential
health services for the child and his or her family, including pre- and post-natal care for
mothers. I he Convention links these goals with ensuring access to child-friendly
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information about preventive and health-promoting behaviour and support to families and
communities in implementing these practices. Implementation of the principle of non
discrimination requires that girls, as well as boys, have equal access to adequate nutrition,
safd environments, and physical as well as mental health services. There is a need to
adopt effective and appropriate measures to abolish harmful traditional practices affecting
the health of children, particularly girls, including early marriage, female genital
mutilation, preferential feeding and care of male children. (18) Children with disabilities
should;be given the opportunity to enjoy a fulfilling and decent life and to participate '
within jtheir community.
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23. States parties should provide a safe and supportive environment for adolescents, that
ensures the opportunity to participate in decisions affecting their health, to build life
skills, to acquire appropriate information, to receive counselling and to negotiate the
health-behaviour choices they make. The realization of the right to health of adolescents
is dependent on the development of youth-friendly health care, which respects
confidentiality and privacy and includes appropriate sexual and reproductive health
services.
24. In all policies and programmes aimed at guaranteeing the right to health of children
and adolescents their best interests shall be a primary consideration.
Older persons
25. With regard to the realization of the right to health of older persons, the Committee,
in accordance with paragraphs 34 and 35 of General Comment No. 6 (1995), reaffirms
the importance of an integrated approach, combining elements of preventive, curative and
rehabilitative health treatment. Such measures should be based on periodical check-ups
lot both sexes, physical as well as psychological rehabilitative measures aimed at
maintaining the functionality and autonomy of older persons; and attention and care for
chronically and terminally ill persons, sparing them avoidable pain and enabling them to
die with dignity.
Persons with disabilities
26. The Committee reaffirms paragraph 34 of its General Comment No. 5, which
addresses the issue of persons with disabilities in the context of the right to physical and
mental health. Moreover, the Committee stresses the need to ensure that not only the
public health sector but also private providers of health services and facilities comply
with the principle of non-discrimination in relation to persons with disabilities.
Indigenous peoples
27. In the light of emerging international law and practice and the recent measures taken
by States in relation to indigenous peoples, (19) the Committee deems it useful to identify
elements that would help to define indigenous peoples' right to health in order better to
enable States with indigenous peoples to implement the provisions contained in article 12
o deT/T TeS and medici"es- States sh0Llld Provide resources for indigenous peoples
design, dehver and control such services so that they may enjoy the highest attainable
standard of physical and mental health. The vital medicinal plants, animak and minerals
necessary to the fu 1 enjoyment of health of indigenous peoples should also be protected
ft Cor?m!ttee notes that’111 indigenous communities, the health of the individual is
re pecTthe Com.6 tT
-T 'TX35 " Wh°le
haS 3 collective dimension. In this
diTlaiiln^f H
conslders|that development-related activities that lead to the
displacement ol indigenous peoples against their will from their traditional territories and
en vironment, denying them their sources of nutrition and breaking their symbiotic
relationship with their lands, has a deleterious effect on their health.
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Limitations
exercke of Lh 6 f d h
S°met'mes used by States ^.grounds for limiting the
XT T?
fundamental nghts. The Committee wishes to emphasize that the
enant s limitation clause, article 4, is primarily intended to protect the rights of
SteTX'wS
t0 '’‘T1 th£ •mP°SitiOn °f limitati0nS
States' Consequently a
trX PartyThJCh’ f0r eXamPle’ restrlcts the movement of, or incarcerates, persons with
belTTedt1>be oZ6 dT 38 HIV/AIDS’refuses t0 allow doctors to treat persons
believed to be opposed to a government, or fails to provide immunization against the
community s major infectious diseases, on grounds such as national security or the
Zont011 °h PT 'C °i
’ haS the bU1’den ofJustifying such serious measures in
acco dance wthleT eleme"t',dentified in artic|e 4. Such restrictions must be in
the naZ of T T 3 ’? Z ln,ternatlOnal huma" rights standards, compatible with
nature of the rights protected by the Covenant, in the interest of legitimate aims
pursued, and strictly necessary for the promotion of the general welfare in a democratic
ou v i u i y.
29. In line with article 5.1, such limitations must be proportional, i.e. the least restrictive
sichT tetmUSt
3 P1? Where SeVeral typ6S Of ^i^ions are available . Even where
Tn ihT rr
£
dS ofProtectlngPublic health are basically permitted they
should be of hmited duration and subject to review.
meo, tney
H. STATES PARTIES' OBLIGATIONS
General legal obligations
various obligations wh.ch are of immediate effect. States parties have immediate
exerli eZhhoutd0" t0
r‘-ght t0 he31th’ SUCh 3S the gUarantee that the right will be
without discnmmation of any kind (art. 2.2) and the obligation to take steps
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itxxsbe de,iberat -«
32 As with all other rights in the Covenant, there is a strong presumption that
etrogressive measures taken in relation to the right to health are not permissible If anv
^''herately retrogressive measures are taken, the State party has the burden of proving
tha
ha7 brn lntJ.0duced after the most ireful consideration of all alternatives aid
hat they are. duly justified by reference to the totality of the rights provided for in the
Covenant m the context of the full use of the State party's maximum available resources
respect requires States to refrain from interfering directly or indirectly with the
enjoyment of the right to health. The obligation to protect requires States to take
Ihe38^68 !hat
th'rd Part'eS fr°m interfering with article 12 guarantees Finally
h d 6 ''g
J0/|/y?ZreqUlreS StateS t0 ad°pt aPProPr*ate legislative, administrative ’
right tMiealt^1013 ’ Pr0m0t'0nal and Other measures towa>-ds the full realization of the
llgllL LU IlCdltn.
*
Specific legal obligations
34. In particular States are under the obligation to respect the right to health by inter
o det?31"'"8 fr°m denying °r l,mitln8 eqUal aCCess for a" Persons’ including^prisoners
and na 1 7’
S5ekerS
iIlega’ immigrant^ to preventive, curative
and pall ative health services; abstaining from enforcing discriminatory practices as a
tate policy, and abstaining from imposing discriminatory practices relating to women's
health status and needs. Furthermore, obligations to respect include a State's obligation to
re rain from prohibiting or impeding traditional preventive care, healing practices and
e icmes, from marketing unsafe drugs and from applying coercive medical treatments
nless oni an exceptional basis for the treatment of mental illness or the prevention and
control of communicable diseases. Such exceptional cases should be subject to specific
t nd restrictive conditions, respecting best practices and applicable international P
standaids, including the Principles for the Protection of Persons with Mental Illness and
the Improvement of Mental Health Care. (24)
In addition, States should refrain from limiting access to contraceptives and other means
of maintaining sexual and reproductive health, from censoring, withholding or
mtent.onally misrepresenting health-related information, including sexual education and
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information as well as from preventing people's participation in health-related matters
States should also refram from unlawfully polluting air, water and soil, e.g. through
himT Stfe-°Wned facilities’ from usi"S or testing nuclear, biological or
chemical weapons id such testing results in the release of substances harmful to human
health, and from limiting access to health services as a punitive measure, e.g. during
armed conflicts in violation of international humanitarian law.
S 01?ati0nS t0 Protect .include, inter alia, the duties of States to adopt legislation or to
take other measures ensuring equal access to health care and health-related services
provided by third parties; to ensure that privatization of the health sector does not
constitute a threat to the availability, accessibility, acceptability and quality of health
mldicine^hvfh aH T‘CeS:'J° C°ntr01 the marketing of medical equipment and
medicines by third parties; and to ensure that medical practitioners and other health
S^nr0"3 S m
apPropriate standards of education, skill and ethical codes of conduct
States
also obliged to ensure that harmful social or traditional practices do not
interfere with access to pre- and post-natal care and family-planning- to prevent third
Par^s from coercing women to undergo traditional practices, e.g. female genital
mutilation; and to take measures to protect all vulnerable or marginalized groups of
society in particular women, children, adolescents and older persons, in the light of
‘xpr'ssi0:s o,f,lol““-StatM sh“"id
~ >!«■. bird P.£i no,
limit people's access to health-related information and services.
m6thThe
•
‘0? ‘0A??/recluires States Parties, inter alia, to give sufficient recognition
enisl t‘8
]
'n
nati°nal P°litiCaI and legal systems’ Preferably by way o?
leg slative implementation, and to adopt a national health policy with a detailed plan for
realizing the right to health. States must ensure provision of health care including
°n PT3"1™5 againSt the maj°r inPecti0US diseases and eLt r equa8! access
for all to the underlying determinants of health, such as nutritiously safe foodl amJ potaSe
rinkmg water, basic sanitation and adequate housing and living conditions Public health
mfrastructures should provide for sexual and reproductive health services ncludinLafo
mo herhood, particularly in rural areas. States have to ensure the ZL a e tnhZ o'
doctors and other medical personnel, the provision of a sufficient nuXLhZX
clinics and other health-related facilities, and the promotion and support of the' P
’
regard to’XaLTlT?
C0Unsellin8 and mentaI heakh services, with due
g d.to equitable distribution throughout the countiy. Further obligations include the
provision of a public, private or mixed health insurance system whifh is affordable for
all, the promotion of medical research and health education, as well as iXmation
=R=rSS5sS=r
SsSSSSsSSsS
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policy to minimize the risk of occupational accidents and diseases, as well as to provide a
coherent national policy on occupational safety and health services. (25)
?
t3|17n'tThek|bIlSa)tlOn t0^Z tfacilitate) requires States inter alia to take positive measures
hat enable and assist individuals and communities to enjoy the right tohealth States
° °b"Sed
a specific right contained in the C^enaXhen
dividuals or a group are unable, for reasons beyond their control, to realize that right
italZXtvIe^ 8dat'°f't1"
d“ination of appropriate information relating to
healthy lifestyles and nutrition, harmful traditional practices and the availability of
sei vices, (iv) supporting people in making informed choices about their healtlJ
International obligations
38 In its General Comment No. 3, the Committee drew attention to the obligation of all
a es parties to take steps, individually and through international assistance^
cooperation, especially economic and technical, towards the full realization of the rights
Kcogmzed m the Covenant, such as the right to health. In the spirit of article 56 of the '
and 23 and the Al aT'T
SPeC,f'C provisions of tlle Covenant (articles 12, 2.1,22
nd 23) and the Alma-Ata Declaration on primary health care, States parties should
ecogmze the essential role of international cooperation and comply with their
health'^ th’t0 take,J°lnt and se?arate action t0 achieve the full realization of the right to
health. In this regard. States parties are referred to the Alma-Ata Declaration which8
proclaims that the existing gross inequality in the health status of the people, particularly
between developed and developing countries, as well as within countries, is politically Y
cXrLanrd?6tC°nOm,Ca Y UnaCCeptable and is’ therefore, of common concern to all
i
UUUIIUIUS.
I
parties by way of legal or political means, in accordance with the Charter of the United
Nations and applicable international law. Depending on the availability of resources
States should facilitate access to essential health facilities, goods and services in other
countries, wherever possible and provide the necessary aid when required. (27) States
parties should ensure that the right to health is given due attention in international
agi cements and, to that end, should consider the development of further legal
instruments. In relation to the conclusion of other international agreements, States parties
tn Ha
SteiPSit0 e1SUre that theSe ,nstruments do not adversely impact upon the right
to health. Similarly, States parties have an obligation to ensure that their actions as
members of international organizations take due account of the right to health
I,
Accordingly, States parties which are members of international financial institutions,
notably the International Monetary Fund, the World Bank, and regional development
banks, should pay greater attention to the protection ol the right to health in inlluencing
the lending policies, credit agreements and international measures of these institutions.
1
40. States parties have a joint and individual responsibility, in accordance with the
Charter of the United Nations and relevant resolutions of the United Nations General
Assembly and of the World Health Assembly, to cooperate in providing disaster relief
and humanitarian assistance in times of emergency, including assistance to refugees and
internally displaced persons. Each State should contribute to this task to the maximum ol
its capacities. Priority in the provision of international medical aid, distribution and
management of resources, such as safe and potable water, food and medical supplies, and
financial aid should be given to the most vulnerable or marginalized groups of the
population. Moreover, given that some diseases are easily transmissible beyond the
frontiers of a State, the international community has a collective responsibility to address
this problem. The economically developed States parties have a special responsibility and
interest to assist the poorer developing States in this regard.
41. States parties should refrain at all times from imposing embargoes or similar
measures restricting the supply of another State with adequate medicines and medical
equipment. Restrictions on such goods should never be used as an instrument of political
and economic pressure. In this regard, the Committee recalls its position, stated in
General Comment No. 8, on the relationship between economic sanctions and respect for
economic, social and cultural rights.
42. While only States are parties to the Covenant and thus ultimately accountable for
compliance with it, all members of society - individuals, including health professionals,
families, local communities, intergovernmental and non-governmental organizations,
civil society organizations, as well as the private business sector - have responsibilities
regarding the realization of the right to health. State parties should therefore provide an
environment which facilitates the discharge of these responsibilities.
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Core obligations
43. In General Comment No. 3, the Committee confirms that States parties have a core
obligation to ensure the satisfaction of, at the very least, minimum essential levels of each
of the rights enunciated in the Covenant, including essential primary health care. Read in
conjunction with more contemporary instruments, such as the Programme of Action of
the International Conference on Population and Development, (28) the Alma-Ata
Declaration provides compelling guidance on the core obligations arising from article 12.
Accordingly, in the Committee's view, these core obligations include at least the
following obligations:
(a) To ensure the right of access to health facilities, goods and services on a nondiscriminatory basis, especially for vulnerable or marginalized groups;
l£o
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(b) To ensure access to the minimum essential food which is nutritionally adequate and
safe, to ensure freedom from hunger to everyone;
X°„“Neba"C 5helKr' h0"Sin8 and Sani'a,i”n' “d m
“W’b'
(d) To provide essential drugs, as from time to time defined under the WHO Action
Programme on Essential Drugs;
(e) To ensure equitable distribution of all health facilities, goods and services;
(0 To adopt and implement a national public health strategy and plan of action, on the
basis of epidemiological evidence, addressing the health concerns of the whole
population, the strategy and plan of action shall be devised, and periodically reviewed on
“S'S of a participatory and transparent process; they shall include methods, such as
right to health mdicators and benchmarks, by which progress can be closely monitored;
the process by which the strategy and plan of action are devised, as well as their content,
shall give particular attention to all vulnerable or marginalized groups.
44. The Committee also confirms that the following
are obligations of comparable
priority:
(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and child health
care;
com^ifnky'de immUniZat‘On against the maJor infectious diseases occurring in the
(c) To take measures to prevent, treat and control epidemic and endemic diseases;
(d) To provide education and access to information concerning the main health problems
in the community, including methods of preventing and controlling them;
(e) To provide appropriate training for health personnel, including education on health
and human rights.
45. lor the avoidance of any doubt, the Committee wishes to emphasize that it is
parti'Cularly incumbent on States parties and other actors in a position to assist, to provide
international assistance and cooperation, especially economic and technical" (29) which
enable developing countries to fulfil their core and other obligations indicated in
paragraphs 43 and 44 above.
I.
III. VIOLATIONS
46. When the normative content of article 12 (Part I) is applied to the obligations of
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States parties (Part II), a dynamic process is set in motion which facilitates identification
of violations of the right to health. The following paragraphs provide'illustrations of
violations of article 12.
‘f
47. In determining which actions or omissions amount to a violation of the right to:health,
it is important to distinguish the inability from the unwillingness of a State party to
comply with its obligations under article 12. This follows from article 12.1, which speaks
of the highest attainable standard of health, as well as from article 2.1 of the Covenant,
which obliges each State party to take the necessary steps to the maximum of its ayailable
resources. A State which is unwilling to use the maximum of its available resources foi
the realization of the right to health is in violation of its obligations under article 12. If
resource constraints render it impossible for a State to comply fully with its Covenant
obligations, it has the burden of justifying that every effort has nevertheless been made to
use all available resources at its disposal in order to satisfy, as a matter of priority, the
obligations outlined above. It should be stressed, however, that a State party cannot,
under any circumstances whatsoever, justify its non-compliance with the core obligations
set out in paragraph 43 above, which are non-derogable.
48. Violations of the right to health can occur through the direct action of States or other
entities insufficiently regulated by States. The adoption of any retrogressive measures
incompatible with the core obligations under the right to health, outlined in paragiaph 43
above, constitutes a violation of the right to health. Violations through acts of commission
include the formal repeal or suspension of legislation necessary for the continued
enjoyment of the right to health or the adoption of legislation or policies which are
manifestly incompatible with pre-existing domestic or international legal obligations in
relation to the right to health.
49. Violations of the right to health can also occur through the omission or failure of
States to take necessary measures arising from legal obligations. Violations through acts
of omission include the failure to take appropriate steps towards the full realization of
everyone's right to the enjoyment ol the highest attainable standard ol physical and
mental health, the failure to have a national policy on occupational safety and health as
well as occupational health services, and the failure to enforce relevant laws.
Violations of the obligation to respect
50. Violations of the obligation to respect are those State actions, policies or laws that
contravene the standards set out in article 12 of the Covenant and are likely to result in
bodily harm, unnecessary morbidity and preventable mortality. Examples include the
denial of access to health facilities, goods and services to particular individuals or groups
as a result of de jure or de facto discrimination; the deliberate withholding or
misrepresentation of information vital to health protection or treatment; the suspension of
legislation or the adoption of laws or policies that interfere with the enjoyment of any of
the components of the right to health; and the failure of the State to take into account its
legal obligations regarding the right to health when entering into bilateral or multilateral
agreements with other States, international organizations and other entities, such as
multinational corporations.
I
Violations of the obligation to protect
lolating the right to health of others; the failure to protect consumers and workers from
pmcticcs deli .mental to health, c.g. by employers and manufacturers of medicines or
food the failure to discourage production, marketing and consumption of tobacco
narcotics and other harmful substances; the failure to protect women against violence or
< piosccute peipetrators; the failure to discourage the continued observance of harmful
traditional medical or cultural practices; and the failure to enact or enforce laws to
prevent the pollution of water, air and soil by extractive and manufacturing industries.
Violations of the obligation to fulfil
52. Violations ol the obligation to fulfil occur through the failure of States parties to take
all necessary steps to ensure the realization of the right to health. Examples include the
failure to adopt or implement a national health policy designed to ensure the right to
heal h for everyone; insufficient expenditure or misallocation of public resources which
results in the non-enjoyment of the right to health by individuals or groups, particularly
the vulnerable or marginalized; the failure to monitor the realization of the right to health
at the national level, for example by identifying right to health indicators and
benchmarks; the failure to take measures to reduce the inequitable distribution of health
faCJ n c H00dS and]serv!ces;the failure t0 adopt a gender-sensitive approach to health;
and the failure to reduce infant and maternal mortality rates.
IV. IMPLEMENTATION AT THE NATIONAL LEVEL
Framework legislation
53. The most.appropriate feasible measures to implement the right to health will vary
significantly from one State to another. Every State has a margin of discretion in
assessing which measures are most suitable to meet its specific circumstances. The
Covenant, however, clearly imposes a duty on each Slate to take whatever steps are
necessary to ensure that everyone has access to health facilities, goods and services so
that they can enjoy, as soon as possible, the highest attainable standard of physical and
mental health. This requires the adoption of a national strategy to ensure to all the
enjoyment of the right to health, based on human rights principles which define the
objectives of that strategy, and the formulation of policies and corresponding right to
health indicators and benchmarks. The national health strategy should also identify the '
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resources available to attain defined objectives, as well as the most cost-effective way of
using those resources.
54. The formulation and implementation of national health strategies and plans of action
should respect, inter alia, the principles of non-discrimination and people's participation.
In particular, the right of individuals and groups to participate in decision-making
processes, which may affect their development, must be an integral component of any
policy, programme or strategy developed to discharge governmental obligations under
article 12. Promoting health must involve effective community action in setting priorities,
making decisions, planning, implementing and evaluating strategics to achieve better
health. Effective provision of health services can only be assured if people's participation
is secured by States.
55. The national health strategy and plan of action should also be based on the principles
of accountability, transparency and independence of the judiciary, since good governance
is essential to the effective implementation of all human rights, including the realization
of the right to health. In order to create a favourable climate for the realization of the '
right. States parties should take appropriate steps to ensure that the private business sector
and civil society are aware of, and consider the importance of, the right to health in
pursuing their activities.
56. States should consider adopting a framework law to operationalize their right to
health national strategy. The framework law should establish national mechanisms for
monitoring the implementation of national health strategies and plans of action. It should
include provisions on the targets to be achieved and the time-frame for their achievement;
the means by which right to health benchmarks could be achieved; the intended
collaboration with civil society, including health experts, the private sector and
international organizations; institutional responsibility for the implementation of the right
to health national strategy and plan of action; and possible recourse procedures. In
monitoring progress towards the realization of the right to health. States parties should
identify the factors and difficulties affecting implementation of their obligations.
Right to health indicators and benchmarks
57. National health strategies should identify appropriate right to health indicators and
benchmarks. The indicators should be designed to monitor, at the national and
international levels, the State party's obligations under article 12. States may obtain
guidance on appropriate right to health indicators, which should address different aspects
of the right to health, from the ongoing work of WHO and the United Nations Children's
Fund (UNICEF) in this field. Right to health indicators require disaggregation on the
prohibited grounds of discrimination.
58. Having identified appropriate right to health indicators, States parties are invited to
set appropriate national benchmarks in relation to each indicator. During the periodic
reporting procedure the Committee will engage in a process of scoping with the State
party. Scoping involves the joint consideration by the State party and the Committee of
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the indicators and national benchmarks which will then provide the targets to be achieved
during the next reporting period. In the following five years, the State party will use these
national benchmarks to help monitor its implementation of article 12. Thereafter in the
subsequent reporting process, the State party and the Committee will consider whether or
not the benchmarks have been achieved, and the reasons for any difficulties that may
have been encountered.
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Remedies and accountability
SO. Any person or group victim of a violation of the right to health should have access to
a y.ejudlcial opr o^er appropriate remedies at both national and international levels.
. . 1 yictlms of such violations should be entitled to adequate reparation, which may
take the form of restitution, compensation, satisfaction or guarantees of non-repetition.
ational ombudsmen, human rights commissions, consumer forums, patients' rights
associations or similar institutions should address violations of the right to health.
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60. The incorporation in the domestic legal order of international instruments recognizing
the right to health can significantly enhance the scope and effectiveness of remedial
measures and should be encouraged in all cases. (31) Incorporation enables courts to
adjudicate violations of the right to health, or at least its core obligations by direct
reference to the Covenant.
61. Judges and members of the legal profession should be encouraged by States parties to
pay greater attention to violations of the right to health in the exercise of their functions.
62. States parties should respect, protect, facilitate and promote the work of human rights
advocates and other members of civil society with a view to assisting vulnerable or
marginalized groups in the realization of their right to health.
V. OBLIGATIONS OF ACTORS OTHER THAN STATES PARTIES
63. The role of the United Nations agencies and programmes, and in particular the key
function assigned to WHO in realizing the right to health at the international, regional
and country levels, is of particular importance, as is the function of UNICEF in relation
to the right to health of children. When formulating and implementing their right to
health national strategies, States parties should avail themselves of technical assistance
and cooperation of WHO. Further, when preparing their reports. States parties should
utilize the extensive information and advisory services of WHO with regard to data
collection, disaggregation, and the development of right to health indicators and
benchmarks.
64. Moreover, coordinated efforts for the realization of the right to health should be
maintained to enhance the interaction among all the actors concerned, including the
various components of civil society. In conformity with articles 22 and 23 of the
Covenant, WHO, The International Labour Organization, the United Nations
Kf
Development Programme, UNICEF, the United Nations Population Fund, the World
Bank, regional development banks, the International Monetary Fund, the World Trade
Organization and other relevant bodies within the United Nations system, should
cooperate effectively with States parties, building on their respective expertise, in relation
to the implementation of the right to health at the national level, with due respect to their
individual mandates. In particular, the international financial institutions, notably the
World Bank and the International Monetary Fund, should pay greater attention to the
protection of the right to health in their lending policies, credit agreements and structural
adjustment programmes. When examining the reports of States parties and their ability to
meet the obligations under article 12, the Committee will consider the effects of the
assistance provided by all other actors. The adoption of a human rights-based approach
by United Nations specialized agencies, programmes and bodies will greatly facilitate
implementation of the right to health. In the course of its examination of States parties'
reports, the Committee will also consider the role of health professional associations and
other non-governmental organizations in relation to the States' obligations under article
12.
65. The role of WHO, the Office of the United Nations High Commissioner for Refugees,
the International Committee of the Red Cross/Red Crescent and UNICEF, as well as non
governmental organizations and national medical associations, is of particular importance
in relation to disaster relief and humanitarian assistance in times of emergencies,
including assistance to refugees and internally displaced persons. Priority in the provision
of international medical aid, distribution and management of resources, such as safe and
potable water, food and medical supplies, and financial aid should be given to the most
vulnerable or marginalized groups of the population.
Adopted on 11 May 2()()().
Notes
1. For example, the principle of non-discrimination in relation to health facilities, goods
and services is legally enforceable in numerous national jurisdictions.
2. In its resolution 1989/11.
3. The Principles for the Protection of Persons with Mental Illness and for the
Improvement of Mental Health Care adopted by the United Nations General Assembly in
1991 (resolution 46/119) and the Committee's General Comment No. 5 on persons with
disabilities apply to persons with mental illness; the Programme of Action of the
International Conference on Population and Development held at Cairo in 1994, as well
as the Declaration and Programme for Action of the Fourth World Conference on
Women held in Beijing in 1995 contain definitions of reproductive health and women's
health, respectively.
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4 Common article 3 of the Geneva Conventions for the protection of war victims (1949)Additional Protocol I (1977) relating to the Protection of Victims of International Armed’
Conflicts art. 75 (2) (a); Additional Protocol II (1977) relating to the Protection of
Victims of Non-International Armed Conflicts, art. 4 (a).
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5. See WHO Model List of Essential Drugs, revised December 1999 WHO Drue
Information, vol. 13, No. 4, 1999.
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6. Unless expressly provided otherwise, any reference in this General Comment to health
facilities goods and services includes the underlying determinants of health outlined in
paras. 11 and 12 (a) of this General Comment.
7. See paras. 18 and 19 of this General Comment.
8. See article 19.2 of the International Covenant on Civil and Political Rights. This
General Comment gives particular emphasis to access to information because of the
special importance of this issue in relation to health.
9. In the literature and practice concerning the right to health, three levels of health
care
are frequently referred to: primary health care typically deals with common and
relatively minor illnesses and is provided by health professionals and/or generally trained
doctors working within the community at relatively low cost; secondary health care is
provided in centres, usually hospitals, and typically deals with relatively common minor
or serious illnesses that cannot be managed at community level, using specialty-trained
health professionals and doctors, special equipment and sometimes in-patient care at
comparatively higher cost; tertiary health care is provided in relatively few centres,
typically deals with small numbers of minor or serious illnesses requiring specialtytrained health professionals and doctors and special equipment, and is often relatively
expensive. Since forms of primary, secondary and tertiary health care frequently overlap
and often interact, the use of this typology does not always provide sufficient
distinguishing criteria to be helpful for assessing which levels of health care States parties
must provtde, and is therefore of limited assistance in relation to the normative
understanding of article 12.
10. According to WHO, the stillbirth rate is no longer commonly used, infant and underfive mortality rates being measured instead.
11. Prenatal denotes existing dr occurring before birth; perinatal refers to the period
shortly before and after birth (in medical statistics the period begins with the completion
of 28 weeks of gestation and is variously defined as ending one to four weeks after birth);
neonatal, by contrast, covers the period pertaining to the first four weeks after birth;
while post-natal denotes occurrence after birth. In this General Comment, the more
generic terms pre- and post-natal are exclusively employed.
12. Reproductive health means that women and men have the freedom to decide if and
when to reproduce and the right to be informed and to have access to safe, effective.
affordable and acceptable methods of family planning of their choice as well as the right
of access to appropriate health-care services that will, for example, enable women to go
safely through pregnancy and childbirth.
13. The Committee takes note, in this regard, of Principle 1 of the Stockholm Declaration
of 1972 which states: "Man has the fundamental right to freedom, equality and adequate
conditions of life, in an environment of a quality that permits a life of dignity and well
being", as well as of recent developments in international law, including General
Assembly resolution 45/94 on the need to ensure a healthy environment for the well
being of individuals; Principle I of the Rio Declaration; and regional human rights
instruments such as article 10 of the San Salvador Protocol to the American Convention
on Human Rights.
14. ILO Convention No. 155, art. 4.2.
15. See para. 12 (b) and note 8 above.
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16. For the core obligations, see paras. 43 and 44 of the present General Comments.
17. Article 24.1 of the Convention on the Rights of the Child.
18. See World Health Assembly resolution WHA47.10, 1994, entitled "Maternal and i
child health and family planning: traditional practices harmful to the health of women
and children".
19. Recent emerging international norms relevant to indigenous peoples include the ILO
Convention No. 169 concerning Indigenous and Tribal Peoples in Independent Countries
(1989); articles 29 (c) and (d) and 30 of the Convention on the Rights of the Child
(1989); article 8 (j) of the Convention on Biological Diversity (1992), recommending that
States respect, preserve and maintain knowledge, innovation and practices of indigenous
communities; Agenda 21 of the United Nations Conference on Environment and
Development (1992), in particular chapter 26; and Part I, paragraph 20, of the Vienna
Declaration and Programme of Action (1993), stating that States should take concerted
positive steps to ensure respect for all human rights of indigenous people, on the basis of
non-discrimination. See also the preamble and article 3 of the United Nations Framework
Convention on Climate Change (1992); and article 10 (2) (e) of the United Nations
Convention to Combat Desertification in Countries Experiencing Serious Drought and/or
Desertification, Particularly in Africa (1994). During recent years an increasing number
of States have changed their constitutions and introduced legislation recognizing specific
rights of indigenous peoples.
20. See General Comment No. 13, para. 43.
21. See General Comment No. 3, para. 9; General Comment No. 13, para. 44.
22. See General Comment No. 3, para. 9; General Comment No. 13, para. 45.
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23. According to General Comments Nos. 12 and 13, the obligation to fulfil incorporates
an obligation to facilitate and an obligation to provide. In the present General Comment,
the obligation to fulfil also incorporates an obligation to promote because of the critical
importance of health promotion in the work of WHO and elsewhere.
24. General Assembly resolution 46/119 (1991).
25. Elements of such a policy are the identification, determination, authorization and
control of dangerous materials, equipment, substances, agents and work processes, the
provision of health information to workers and the provision, if needed, of adequate
protective clothing and equipment; the enforcement of laws and regulations through
adequate inspection; the requirement of notification of occupational accidents and
diseases, the conduct of inquiries into serious accidents and diseases, and the production
of annual statistics; the protection of workers and their representatives from disciplinary
measures for actions properly taken by them in conformity with such a policy, and the
provision of occupational health services with essentially preventive functions. See ILO
Occupatidmal Safety and Health Convention, 1981 (No. 155) and Occupational Health
Services Convention, 1985 (No. 161).
26. Article II, Alma-Ata Declaration, Report of the International Conference on Primary
Health Care, Alma-Ata, 6-12 September 1978, in: World Health Organization, "Health
for All" Series, No. 1, WHO, Geneva, 1978.
27. See para. 45 of this General Comment.
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28. Report of the International Conference on Population and Development, Cairo, 5-13
September 1994 (United Nations publication, Sales No. E.95.XIII. 18), chap. 1, resolution
1, annex, chaps. VII and VIII.
29. Covenant, art. 2.1.
30. Regardless of whether groups as such can seek remedies as distinct holders of rights,
States parties are bound by both the collective and individual dimensions of article 12.
Collective rights are critical in the field of health; modern public health policy relies
heavily on prevention and promotion which are approaches directed primarily to groups.
31. See General Comment No. 2, para. 9.
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People's
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People's Charter For Health
INTRODUCTION
^2s?al,h - “
Governments and the international bodies are fully responsible for this failure
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effort to put the 9oals of b.alth
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Process elicited unprecedented
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s oMla~",
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^-"L::rt7as„:x\ixxv;“ered,fi,e ™in ,hem-
The Ways Forward. People from all oveVthe^ H^lth Services; Environment and Survival; and
service failure as well as those of successf I
i0- ■ presented testimonies of deprivation and
concurrent sessions made t possib
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°r9anization- °ver a hundred
different aspects of the maior themes and Part,ClpantS
share a"d discuss in greater detail
The five days event gave p rticipants the^^soXT^
t
eXperiences and “ncerns.
put forward the failures of their respective no
in their °wn idiom. They
decided to fight together so that health and 9°Ver"m®|nts and international organizations and
pciley oial<ers agendas
the common tool of a worZide dtfzens mo
t
n6^'
experteoces, the, have
Charter frOm now
will be
ement committed to make the Alma- Ata dream
reality.
encourage and invite everyone who shares our concerns and aims to join
us by endorsing the
2------------------
People's Charterfor Health
IM
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preamble
a fundamental human right
Xli^X^eZ
of poor and marginalised people. Health for all mZ
u
of iH-health and the deaths
challenged, that globalisation has to be opD 1 T th^ P°werful interests have to be
to be drastically changed. This Charter builds on peisoecf1 P°''Z' 306 eCOnomic Priorities have
been heard before, if at all. It encourages people to devel
.P.e°ple whose voices have rarely
accountable local authorities national
eveloP their own solutions and to hold
corporations.
natlOnal governments, international organisations and
VISION
healthy life for all is a realitC Twt utk 63,1 °f °Ur V'Sion of a better
celebrates all life and diversity;
3 WOrld that
,; a- world that enables the y;flowerinn
f reS.peCts' aPPreciates and
to enrich each other; a world in which people's voices nuid th9 °f people's talents and abilities
J-eso„reestoPacEte °hTX the d'C""OnS“ «ves.
There are more than enough
the health crisis
there are people who d^e.^e ^rTang^ec^
PeOP!e. Wh° 9et sick or because
the economy and social policies that are imposed on us."
hS
their r00ts in
In recent decades economic rhanr,
•
(A V0lcefr0r^ Central America)
their access to health care and otherXaXXs haVe PrOf°UnC,ly affected Pe°Ple's health and
between rich a^poo^natioX^w^dened'^^Z^inerTt'^ K h"96"
classes, between men and women and between young and old.65
wate?, sanitation'' sheker'aZ'its'resources'^em'l
I
inCreasin9' The 9ap
betWeen S0Cial
eduCation' safe d™king
crimination continues to preva. It affects both the ocSSd^X^ XS
of the environment threatens erne's healtTesp?01| Z'h9
resultin9 degradation
ulting degradation
UPSUi”^3 0pr|ew c°nflicts while weapons of mass destruchon sdH pos0eZgera9v0e0threaetre ^aS I3660
i
-- - - - -e te maximise
activities of transnational corpoXs^ZX^^^^^^
health and vyell-being of people in both North and South.
^ult of cuts7nXXteZda°XZXhX ^h"056
1^2£Z£2!ydistributed and more inappropriate.'
'VeS and livelihoods,
deteriorated as a
eC°me leSS accessible, more
3
People's Charterfor Health
IU
PRINCIPLES OF THE PEOPLE'S CHARTER FOR. HEALTH
The attainment of the highest possible level of health and well-being is a fundamental
human nght, regardless of a person's colour, ethnic background, religion, endeT ag
abilities, sexual orientation or class.
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The principles of universal, comprehensive Primary Health Care (PHC), envisioned in the
1978 Alma Ata Declaration, should be the basis for formulating policies related to health
he^hTam is nLTed9" ^h'6'
and
h?Ve 9 fundamental responsibility to ensure universal access to quality
“OTdm9 “
priority m local, national and international policy-making.
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el°P™nt, be a top
A CALL FOR ACTION
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n“d ,o Tt’ke “tion at ■»
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9
d m a" SeCt°rS- The demands presented below provide a basis for
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action.
HEALTH AS A HUMAN
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ZXSX"e,u,ty md iuKice H“'‘h
This Charter calls on people of the world to:
!
Support all attempts to implement the right to health
Fight the exploitation of people's health needs for purposes of profit.
4
People's Charterfor Health
IU
TACKLING THE BROADER DETERMINANTS OF HEALTH
Economic challenges
The economy has a profound influence on |
■ - ■
people's health. Economic policies that prioritise
equity, health and social well-being can improve the health of the people as well as the
----- 2 economy,
Political financial, agricultural and industrial policies which respond primarily to < '
capitalist needs,
I’Zand
^ti°nal9overnments
international organisations, alienate people"^
nd livelihoods. The processes of economic globalisation and liberalisation have increased
inequalities between and within nations. Many countries of the world and especially the most
powerfu ones are using their resources, including economic sanctions and military interventions
to consolidate and expand their positions, with devastating effects on people's lives.
This Charter calls on people of the world to:
■
Demand transformation of the World Trade Organisation and the global trading system
so that it ceases to violate social, environmental, economic and health rights of people
and begins to discriminate positively in favour of countries of the South. In order to
protect public health, such transformation must include intellectual property regimes
agreement^1115
RelSted asPects of Intellectual Property Rights (TRIPS)
■
Demand the cancellation of Third World debt.
■
Demand radical transformation of the World Bank and International Monetary Fund so
countries6 lnStltUtl°nS refleCt and active|y promote the rights and interests of developing
■
Demand effective regulation to ensure that TNCs do not have r,_
negative effects on
people's health, exploit their workforce, degrade the environment
or impinge on
national sovereignty.
■
Ensure,that governments implement agricultural policies attuned to people's needs and
access to food"1 andS
thereby 9uaranteeing food security and equitable
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■' Demand that national governments act to protect public health rights in intellectual
, property laws.
Demand the control and taxation of speculative international capital flows.
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■ , Insist that all economic policies be subject to health, equity, gender and environmental
impact assessments and include enforceable regulatory measures to ensure compliance.
Challenge growth-centred economic theories and replace them with alternatives that
create humane and sustainable societies. Economic theories should recognise
environmental constraints, the fundamental importance of equity and health, and the
contribution of unpaid labour, especially the unrecognised work of women.
1
Social and political challenges
Comprehensive social policies have positive effects on people's lives and livelihoods. Economic
globalisation and privatisation have profoundly disrupted communities, families and cultures
Women are essential to sustaining the social fabric of societies everywhere, yet their basic needs
are often ignored or denied, and their rights and persons violated.
5
People's Charterfor Health
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institutions, which are rarely accoun ab e t T'
T
t0
nati°nal and inte™tional
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There is „ urgent need ,ofost^
rhis Charter calls on people of the world to:
I
Demand and support the development and
implementation of comprehensive social
policies with full participation of people.
SnX'dXr™" *he
■ phXT
calls for freea'dcompTtor^qw’^
agenda. This
PMIdren and „on,en. and J’o, i^ady
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part.cu,ar,y 3ld
insti,u,T rh as chiM
9 Pr0VISI°nS- benefit the health °f individuals and
communities
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■
particularly the lives XoXTchJrre^and min^ritieT^5
''h^'65
of individuals,
Oppose sex tourism and the global traffic of women and children.
Environmental challenges
toxic chemicals and pesticidesjo^ of ^od’ 0Z°?e '77 deplet'On' nuclear energy and waste,
reaching effects on people's health The root causes of th fOreStation and soil erosi°n have farexploitation of natural resources the absence of
I
deStruCtl0n lnclude the unsustainable
individualistic and profit-maximisina behav
" 'On9'term holistic ^ion, the spread of
d.s.™dO„mustbecponfrant;j™x“a“^
*
™s
This Charter calls on people of the world to:
inStitUtiOnS and the ^ary
■
f °US actlvitles that impact on the
environment and people's health.
a9’i"st
■
threats to healrh and the environ^,
territories far stricter than those
6
People's Charterfor Health
16c
,
P“S'
1
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change agreement,
Without resorting to hazardous
practices.
u’,y 10 naz^dous or inappropriate technologies and
radioactive waste to poorer
countries and rnarXliTcoZunfeTnd'e^
encourage solutions that minimise waste
production.
pollutionbygopercent.
65
Eluding worker-centred
™Zi„;Z“io°g cZm.““Pa’i0"a'
'
40 Pr“a"'
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anTresZe'5 "h
0 reciuce their consumption and
’"d ^S io the „orkplace. ,,, commumy
°f ''S®*™! and indigenous knowledge
a"‘' 0PPO“
of environmental and
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environmente, degradation and the h’a.th status
social
War, violence, conflict and natural disasters
and children. Increased arms procurement and an ann
--e
•
and deStr°y hUman di9nity-
f^he,r members/ especially women
po»„, „d
fh/s Charter calls on people of the world to:
■
Support camp,ig„s aniJ movemer)K for
I
"d las“"9 Peace, especially in countries
»» “P«Prienc'so“’”Za“d^
' ZonC' ““ °f Ch“d 5°“erS’ “d the
™pe, torture and kiiling ofwome„
i
........................ .. .........
Demand the radical transformation of the UN Sor > r
democratically.
ne UN Security Council so that it functions
Demand that the .........
C ‘
an instrument of aggression
■
Encourage
independent,
people-based initiatives to HPrl=r„
communities and cities areas of peace and zones free of weapons.
7
People's Charterfor Health
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• .
nei9hbo^hoods,
u
Support actions and campaigns for the prevention and reduction of aggressive and
violent behaviour, especially in men, and the fostering of peaceful coexistence.
Support actions and campaigns for the prevention of natural disasters and the reduction
ot subsequent human suffering.
A PEOPLE-CENTERED HEALTH SECTOR
This Charter calls for the provision of universal and comprehensive primary health care
irrespective of people's ability to pay. Health services must be democratic and accountable with
sufficient resources to achieve this.
This Charter calls on people of the world to:
Oppose international and national policies that privatise health care and turn it into a
commodity.
■
Demand that governments promote, finance and provide comprehensive Primary Health
the m°St effectlve waX of addressing health problems and organising public
health services so as to ensure free and universal access.
■
Pressure governments to adopt, implement and enforce
national health and drugs
policies.
Demand that governments oppose the privatisation of public health services and ensure
service? re9
’On °f thS Private medical sector- includin9 charitable and NGO medical
Demand a radical transformation of the World Health Organization (WHO) so that it
responds to health challenges in a manner which benefits the poor, avoids vertical
HeahhlX'
\lntersectoral work' involv« people's organisations in the World
ealth Assembly, and ensures independence from corporate interests.
Promote, support and engage in actions that encourage people's power and control in
ecision-makmg in health at all levels, including patient and consumer rights.
Support, recognise and promote traditional and holistic healing systems and
practitioners and their integration into Primary Health Care.
■
Demand changes in the training of health personnel so that they become more problemnented and practice-based, understand better the impact of global issues in their
ZrTities '
arS enC°Ura9ed t0 WOrk with and resP^t the community and its
-
Demystify medical and health technologies (including medicines) and demand that they
be subordinated to the health needs of the people.
they
'
™™nd tha7esear‘h
health, including genetic research and the development of
edicmes and reproductive technologies, is carried out in a participatory, needs-based
manner by accountable institutions. It should be people- and public health-oriented
respecting universal ethical principles.
1
Support people's rights to reproductive and sexual self-determination and oppose all
iahurthTT II VeS 'H P°PUJatiOn and fami|y inning policies. This support includes the
ight to the full range of safe and effective methods of fertility regulation.
8
People's Charterfor Health
U’>
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PEOPLE'S PARTKIPATiON FOR A HEALTHY WORLD
and
•»
groups and movements, and the media have en ■
democratic, transparent
rl9htS' a Wlde ran9e °f civil society
Build and strengthen people's organisations to
create a basis for analysis and action,
Promote, support and engage in actions that
decision-making in public services at all levels.
encourage people's involvement in
loCal' nati°"al and international
foXat'mXTntS
people-centredsolidaritynZoXcrS™
thr0U9h the establ^ment of
The People‘s"™^------------------a number of orga^Vatio^laOS^
f°r more than a decade. In 1998
Assembly meeting, held in Bangladesh at the end of 2ooo A
t0 f'30 "
intema«°nal
activities were, initiated including regional workshoos the
and P^’^embly
stones and the drafting of a People's Charter for Health Th
°f pe0P,e's health-related
V,eWS °f/itizens and people's organisations from amund th
T'
builds uPon the
opened for endorsement at the Assembly meeting in Savar 8^° I h
f'rSt aPProved and
Charter .s an expression of our common concerns our^iZ f 9?
h'
DeC6mber 200°- The
of our calls for radical action. It is a tool for advocacy and a rZ'
WOrld' and
ne,Works 3nd
J,
9
People's Charterfor Health
"T:-tr°Und “hfch ’
Join Us - Endorse the Charter
”
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9l°bai
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Global Secretariat Coordinator
Hani Serag
Email: secretariat@phmovement.org
Web: www.phmovement.org
Host Organization
Association for Health and Environmental Development
(AHED)
Address: xj Beirut St., APT.# 501 - Heliopolis, Cairo - Egypt
Tel.: +20 2 2565613
Fax:+20 2 2565612
Global Secretariat Committee
Association for Health and
Environmental Development (AHED)
Web: www.ahedegypt.org,
E-mail: ahednet@ahedegypt.org &
hpsp@ahedegypt.org
The Palestinian Medical Relief
Society (PMRS), formerly
UPMRC
Web: www.upmrc.org,
E-Mail: pmrs@pmrs.ps
Arab Resource Collective (ARC)
Web: www.mawared.org,
E-mail: arccyp@spidernet.com.cy
(Cyprus), arcleb@mawared.org
(Lebanon)
I
Ex Global Secretariat Coordinators
Dr. Ravi Naryan (2003-2006)
Email: ravi(a)phmovement.org
Host Organization
The Community Health Cell (CHC), Bangalore, India
Dr. Qasem Chowdhury (2001 - 2003)
Email: 9ksavar@citechc0.net
Host Organization
People s Health Center, Gonnoshasth'aya Kendra (GK)
Savar, Bangladesh.
Web: http://www.sochara.org/
Amendment
°,n D“rber8' “oo'11 was»'
’
wto -
■
The section of War, Violence iand' Conflict
' “ has been amended to include natural disasters.
A new action point, number ■ '
•
J" J?'5 version' was added
demand the end of
toZail kindUrtJerm°re' aCtiOn POint number 7‘ now --ber 8,
....
.'
—/ was amended to read
io ena an kinds of sanctions. An radditional
*''■■■
action point number 11 was added concerning
natural disasters.
10
People's Charterfor Health
in
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PW5
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...
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E
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i
!
'
THE MuMBAi
X>ECIATtATiON
w®
■
.
i
■
r.
’ from
The III International Forum for the
Defence of the People’s Health
I
i
4
Mumbai, India
(A Forum held before the World Social Forum, 16-21 st January 2004)
I
n°
I
PREAMBLE
We, the 700 delegates from 44 countries1, gathered at the
III International Forum for the Defence of the Peoples
Health at Mumbai on 14th and I Sth of January 2004,
•
End Corporate led Globalisation
•
End war and occupation
•
Implement Comprehensive and sustainable Primary
Health Care
reaffirm the validity and relevance of the People's Charter
•
for Health, the foundational document of the People's
Confront the HIV/AIDS epidemic with Primary Health
Care and Health Systems approach
Health Movement, which describes increasing and serious
threats to health in the early 21 st century.
•
Reverse
Environmental damage
caused
by
1
unsustainable development strategies
Since the Charter’s adoption in December 2000 at the
first People’s Health Assembly, at GK Savar, Bangladesh, the
•
End discrimination in the Right to Health
health of the world's poor has worsened and more threats
End corporate-led globalization
to people's health have emerged.
Corporate-led globalization continues
and
to be a major threat to health. Since
environmental threats to health
the People's Charter for Health was
Social, political,
economic
identified as the basic causes of ill health
and the inequitable distribution of
health within and between countries
have increased.
and environmental
adopted in 2000. the International
threats to health
Monetary Fund, the World Bank and
identified as the basic
causes of ill health and the
the World Trade Organisation have
continued to advance .the economic
health of co--porations a’t the expense
The III International Forum for the Defense
inequitable distribution of
of the People's Health provided
health within and between
of global health.
opportunities to hear inspiring testimonies,
countries have increased
The protection of intellectua'I property
from the world's poor and health activists:
(through trade agreements such as the
Denouncing the denial of health to
Trade Related aspects of Intellectual Property Rights,TRI PS)
their communities and their efforts to overcome this injustice.
and unfair trading practices (through the* General
•
Threats to health from the unfair system of global trade
•
and the imperialist policies ofdeveloped countries including
enormous damage to people'1 health.
The tobacco industry offers a clear example:Tobacco kills,
unjust wars and efforts to counter them
The Demands for acknowledgement ofhealth as a universal
•
Agreement on Trade in Services, GATS)1 have caused
human right and the implementation of Comprehensive
Primary Health Care as a strategy to achieve Health for All.
The Forum recognized the particular discrimination suffered
by many groups which makes achieving Health for All even
more difficult. These included women, people with disabilities,
sex workers, children living in difficult circumstances (including
yet transnational companies continue to target youth and
marginalized communities with their tobacco marketing
strategies.
The epidemic of privatizations of water, electricity, education
and health care, imposed by Structural Adjustment Packages
(SAPs), has limited access to or removed the foundation
upon which public health is built.
street children), migrant workers, people with mental disorders,
Public-private partnerships, as promoted by World Bank.
Dalit people, Indigenous peoples in rich and poor countries,
Global Funds and International health agencies including
and all those affected by wars, disasters and conflicts.
WHO, have removed responsibility for health from the
The Forum demanded Health for All, Now! and reiterated that
Another World in which health is a reality for All is necessary
and possible.
The Forum brought together all the concerns and
public sector, essentially privatizing health and treating it as
a commodity rather than a human right. Use'- fees have
further decreased people’s access to health care services.
This Declaration;
experiences shared into a Declaration for action, entitled
Calls for Action by People’s Health'Movement and Civil
"The Mumbai Declaration". This Declaration is an update
on the state of people’s health across the globe at the
Society to:
• Pressure the World Bank and the International
beginning of 2004 and calls on People’s Health Movement,
Monetary Fund to acknowledge their culpability in the
Civil Society and Governments to evolve action in six key
current health care crisis, especially the damage caused
areas to achieve the goal of “Health for All Now!" dream.
by Structural Adjustment Programs;
1
Hua. Cuba. Denmark. Ecuador. Egypl. Erancc. Girm.im Guaivmala. Hong Kong Indi.i.
Argentina. Australia. Bangladesh. Belgium. Brazil. GambcKlia. ( anienxm, Canada. G»sta
U'b’an.m. Mal’aysi^
Nicaragua, Nigeria. Norway. Pakistan, Palestine. Peru. Pbilipi.ines. South Alriea. Sri Lanka. .Sweden^
Iran, Icily. Kenya. Korea, U.....
. K’1
k
.....
Switzerland. Tanzania, Thailand. I SA. LK. Vietnam. Zambia. Zimbabwe.
The Mumbai Declaration
t-H
I
•
Build the Campaign "NoTo Intellectual Property Rights"
Building the global campaign; "No to War, No to
■
in our traditional systems of medicine and our seeds,
WTO. Fight for People's Health";
to resist the efforts of the WTO and translational
Monitoring the impact of war. occupation, and
■
corporations to patent, own and trade in them;
militarization through a global "Occupation Watch";
•
Demand the representation and active participation of
■
people's organisations, health workers, and farmers in
Targeting corporations which benefit from the war
in Iraq, invasions and military, occupations and those
policy-making processes related to Access to Health
that enrich themselves (e.g. arms industry,
•
Expose, shame and stop government officials, academic
pharmaceutical and food companies) by fostering
institutions, and civil society organisations from accepting
ill-health through a "Boycott Bush" campaign;
money from the tobacco and other industries which
■
undermine public interest initiatives internationally and
justice and equality.
nationally.
Calls for Action by Governments
Calls for Action by Governments
•
■
Regulate the entry and behaviour of the corporate
Refuse to take part in unjust and imperialist wars
and occupations
sector in the social services such as health, education,
I
Establish peace initiatives at various levels based on
■
transportation, etc., and ensure that public health
Work for world peace as a key determinant of health.
concerns always take precedence over trade
Implement Comprehensive and
agreements and corporate profit;
•
Resist "TRIPS-plus" through bilateral or regional trade
Sustainable Primary Health Care
Since 2000, the Global Fund and other
agreements driven by the United
international health programmes of
States government and the
institutions it controls:
•
•
WHO, UNICEF and World Bank have
occupation and militarism
continued to promote selective and
Ensure negotiations on "FreeTrade"
have become ever more
vertical health programs which corrupt
treaties and the like are transparent
devastating threats to
and weaken Comprehensive Primary
and democratic and not conducted
people’s health.The
Health Care as defined in the WHO
behind closed doors;
violent imposition of
Alma Ata Declaration.
Resist pressure to privatise health
essential industries (health care,
electricity, water and education)
and renationalise these industries;
•
Since 2000, war.
imperial will has led to
death, injury, and social
1 Health professionals educated in the
4
and environmental
destruction for untold
n^.,pWpl..
developing world and migrating to the
developed world represent a transfer
of billions of dollars from South to
Sign, ratify and implement the
North. This unrequited training
Framework
investment further burdens health
Convention
on
Tobacco Control (FCTC);
systems already suffering from a precarious lack of human
End War and Occupation
to developed countries, but also from the public to the
resources. The "brain drain" flows not only from developing
Since 2000. war occupation and militarism have become
private sector.
ever more devastating threats to people's health.The violent
Traditional and alternative systems of medicine are vibrant
imposition of imperial will has led to death, injury, and social
parts of Comprehensive Primary Health Care.Traditional
and environmental destruction for untold numbers of people.
Birth Attendants provide the first and often the only access
Actions in support of international law and pro-health and
against the war in Iraq; the occupation of Iraq and Palestine;
the construction of the Wall in Palestine are urgently needed
to reproductive health in many areas of the world. These
knowledge and traditions should be validated and their
skills reinforced through continuing education, and support
to the revitalization of local health traditions.
This Declaration;
New areas, relevant to Primary Health Care, not adequately
Calls for Action by People's Health Movement and Civil
Society to;
Strengthen the international anti-war movement through.-
addressed in the Alma Ata Declaration need to be
promoted in an integrated way. These include gender,
environment, disability, mental health and traditional systems
of health.
3
I
9
.............. .......... / s
I he Mumbai Declaration
nt
orphaned by HIV/AIDS and worpen who are more
This Declaration;
vulnerable take a heavy toll.
Calls for Action by People's Health Movement and Civil
Society to;
• Demand that universities and other training institutions
incorporate Comprehensive Primary Health Care into
the curriculum for all health professionals updated to
address gender, environment, disability, mental health,
traditional systems and other issues,
.
to HIV/AIDS and has made an official commitment to
pursue its 3 X 5 goal (3 million persons with AIDS receiving
Anti-retroviral Treatment (ARV) treatment by 2005)
through strengthened health systems. Yet addressing the
HIV/AIDS epidemic requires contextual solutions.
Workers and Traditional Birth Attendants as integi al
.
•
Calls for Action by Governments
and alternative
• Develop national policies on ttraditional
-------
The 3 x 5 initiative focuses on treatment alone, ignoring
the complexity of the epidemic,
members of multi-disciplinary Primary Health Care teams.
can lead to long-term dependency on
l -ligh drug costs
donors;
There is inadequate involvement of
•
persons living with and affected by
medical systems and include them
Establish Comprehensive Primary.
WHO has recently become
stronger in its technical
support to HIV/AIDS and
has made an official
commitment to pursue its
3X5 goal (3 million
persons with AIDS receiving
Anti-retroviral Treatment
(ARV) treatment by 2005)
through strengthened
health systems.
Health Care services based on the
PHM is concerned that the 3
principles and strategies of Alma
X 5 initiative focuses on
treatment alone, ignoring
the complexity of the
epidemic.
Involve marginalised sectors in
•
decision-making regarding policies
that affect them;
Strengthen health systems in the
•
context of access, quality and
equity;
•
We
are however, particularly concerned that:
Lobby for widespread adoption of Community Health
in national health programmes;
I
WHO has recently become stronger in its technical support
Ata outlined in this declaration
and related to local needs and
updated to address gender,
environment, disability, mental
health, traditional systems and other issues.
HIV/AIDS and civil society in planning,
implementation and evaluation
•
There is inadequate budgetary and
related commitments on improving
health systems, particularly Primary
health Care to provide drugs and
general
health
services
and
information in the long term.
.
There is inadequate attention to life
skill education, women s health
empowerment and utilization of
traditional systems of medicine.
While endorsing concern about the HIV/
AIDS epidemic, the need for Primary
Health Care oriented and Health Systems strengthening
approaches to other communicable and non-communicable
Calls for Action by WHO
To reaffirm the principles of Alma Ata and ensure that
comprehensive approaches that focus on primary health
care and strengthen health systems are the basis of all
WHO global and regional strategies.
Confront the HIV/AIDS epidemic
diseases in an integrated way is urgently required.
This Declaration;
Calls for Action by People's Health Movement and Civil
Society to;
• Continue campaigns for the rights of people in poor
countries to receive ARV treatment delivered through
The HIV/AIDS epidemic has continued to worsen since
2000, especially in Africa and increasingly in Asia and
elsewhere. Spreading along migration routes related to
comprehensive PHC services.
•
globalization and to social and economic distress due to
in Patent laws that is expected to escalate the APT
war, global trade and economic policies, HIV/AIDS is now
associated with the resurgence of other communicable
diseases of poverty, such as tuberculosis.
Access to ARV treatment has increased the life expectancy
and quality of life of those who can afford it.The majority
Facilitate Public Interest Litigations to oppose changes
prices.
.
Make the links between the spread of HIV/AIDS and
the underlying societal determinants such as poverty,
war, displacement and participate in efforts to redress
these injustices
of AIDS patients being impoverished are denied access to
treatment in violation of the principles of the international
covenant on social, economic and cultural rights. Children
4
The Mumbai Declaration
I
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Colls for Action by Governments
•
This Declaration;
Develop a comprehensive Primary Health Care
Calls for Action by People’s Health Movement and Civil
O'-iemed and health systems' strengthening approach
Society to;
to address the HIV/AIDS epidemic through
•
interventions, including:
Monitor environmental damage caused by unsustainable
development strategies with specific focus on pesticides,
•
Peer education that includes sexual and reproductive
industrial and military toxic wastes, etc.;
health and rights information;
•
Oppose stigma and promote respect of and care
Link PHM with other organisations working for
environmental justice at the grassroots,
for oeople living with HIV/AIDS:
•
■
struggles and invite them to join in our struggle for the
with HIV/AIDS;
People's Health.
■
Immediate availability of ARV drugs;
■
Support those affected by the epidemic through
Calls for Action by Governments
•
empowerment.
To evolve a comprehensive
approach emphasizing Primary
Health care and health systems'
strengthening
Pass legislation to ensure governments can hold
corporations accountable for environmental damages.
Calls to WHO
•
national and international levels. Join them in their
Increased access to basic services by people living
approaches
including preventive information
Women’s right to health,
including sexual and repro
ductive health, is violated
not only by current socio
economic and political
structures but also by
Work towards reduction of high
drug costs;
•
Enhance involvement of people,
affected communities and civil
The People’s Health Charter asserted
the right to health for all people. We
reaffirm this by noting that the
marginalized groups listed below suffer
and services and ARV treatment;
•
End Discrimination in the
Right to Health
Trafficking of women and
girls is a major public health
problem, little addressed by
governments where the
trafficking is most rampant
society in its planning and
particular and on-going health
problems requiring urgent attention:
•
Around the world, many
women lack access to basic health
care, endangering them and their
families. Women's right to health,
initiatives through proactive dialogue.
including sexual and reproductive health, is violated not
only by current socio-economic and political structures
Reverse Environmental Destruction
but also by religious and cultural fundamentalism.
The People's Charter for Health recognized that
Population control policies violated human rights,
environment, livelihood, and people's health are
including the use of disincentives and such reprehensible
interconnected and environmental degradation is a major
practices as forced sterilization of women. Newer
threat to global health. Since 2000, continuing environmental
contraceptives and reproductive technologies often
destruction has had a highly negative impact on health.
Rivers
ignore hazards to women's health and other ethical
and moral issues;
,rid the world, like the Abra in the Philippines
and the Narmada in India, are in danger of being destroyed,
•
problem, little addressed by governments where the
wno depend on these rivers.
trafficking is most rampant:
Toxins in pesticides, fertilizers, defoliants (such as Agent
•
waste from US Military Bases (such as those in the
•
Philippines), dust from exploded depleted uranium
ordinance (such as thaf used in Iraq, Puerto Rico), and
medical and nuclear waste as well as from mining run-off
Sex-selective abortion is a misuse of technology that
discriminates against the girl child;
Orange and those of the "War on Drugs" of Plan Colombia),
I
Trafficking of women and girls is a major public health
as are the lives and health of the people and communities
The rights of sexual minorities and sex workers,
including access to health care, must be respected;
•
The health and human rights of persons with mental
and exploration for petroleum; are all poisoning our
disorders are currently ignored or inadequately
environment and represent a critical hazard to health.
addressed throughout the world. There is an urgent
need to provide effective community based programs
for persons with [mental illnesses.
I
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f
5
17^
The Mumbai Declaration
•
The unjust social systems like caste in India and ethnic
This Declaration;
discrimination in other parts of the world have created
a health apartheid and human rights reality for the
Calls for Action by People’s health Movement and
Civil Society
socially marginalised;
•
•
Make concerted efforts to incorporate all the above
Indigenous people in developed and developing
marginalized populations, the "unheard and unseen",
countries suffer health problems at a higher rate than
into their networks and facilitate their access to and
the general population of the country in which they
influence in mainstream discourse.
I
I
reside. As they are forced to follow the hegemonic
cultural and development paradigms, they are being
•
Ensure gender equity within the movement and within
their own networks and communities
deprived of traditional knowledge and traditional
systems of medicine and access to basic resources;
Calls for Action by Governments
•
•
The health and other human rights of persons with
Make concerted efforts to incorporate the needs of
marginalized populations, tne "unheard and unseen", in
addressed throughout the world:
health and development sfategies and social policies
in a Right’s context.
Migrant workers living and working in the developed
and developing world suffer poorer health than the
•
•
disabilities are currently ignored or inadequately
•
Ensure availability of disaggregated data on health status
general population surrounding them.Their basic human
and access to health services for different groups ( age.
rights are denied through lack of access to health,
sex. region, ethnicity etc.,) in the community to make
education, housing, etc.:
discrimination to the right to health more transparent
Children living in difficult circumstances, such as street
and enable actions to be taken.
children, AIDS orphans, children of war, etc. face
increasing discrimination. Corporate-led globalization
only increases the poverty in which they live and robs
them of a dignified future.
!
IN CONCLUSION
We, the members of the People’s Health Movement and the participants of the III International Health PorLm for the
Defense of People’s Health commit ourselves to promoting the People’s Charter for Health 2000 and the concerns and
calls for action of the Mumbai Declaration 2004.
•
We believe that an Another World is Possible;
•
A Healthy World is Possible;
•
Health for All Now! is Possible;
Join us - Endorse the People's Charter for Health 2000 - Endorse the Mumbai Declaration 2004
•
i
SIGN ON AND PROMOTE the People's Charter for Health
(visit http.7/www.phmovement.org/charter/index.html)
•
SUPPORT the Million Signature Campaign demanding Health for All, Now!
(visit www.TheMillionSignatureCampaign.org)
•
PROMOTE the Mumbai Declaration
4
People’s Health Movement
Global Secretariat,
C/O CHC,
# 367, Jakkasandra 1st Main, 1st Block, Koramangala, Bangalore - 560 034.
Tel : +91-80-51280009 Fax : +91-80-25525372
Email . secretariat©phmovement.org Website : www.phmovement.org
nr
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E3 WHO and UNAIDS
St
s.
||1
People’s Health Movement
Evolve a comprehensive approat- that strengthens primary health care and health
systems, with built-in indicators
if
b
^4- ’Tflj
progress.
§
Stop narrowly-focused vertical programmes.
&
Urge all governments to follow toe UN's International Guidelines on HIV infection
and AIDS and Human Rights.
Include non-priority countries in the 3x5 initiative.
1HI
Take appropriate action in 'low prevalence countries'.
Start immediate action for sub-Saharan African countries.
1
Monitor the impact of trade agreements on health.
El World Bank, International Monetary Fund and
PREAMBLE
World Trade Organization
:^-
Health is a social, economic and political issue and, above all. a fundamental human
Be accountable for social disasters caused by anti-poor macroeconomic policies.
t>
right. Inequality, poverty, exploitation, violence and injustice are at the root of
Cancel debts of all poor countries, especially those identified as vulnerable to HIV
ill health. Achieving health for all means that powerful interests working against
and AIDS.
people's well-being have to be challenged, corporate globalisation has to be opposed
Stop free trade agreements, privatisation of essential services, and the
commercialisation of health care.
and political and economic priorities have to be drastically changed.
Finance HIV and AIDS interventions with grants instead of loans.
also a public health issue that requires people-oriented health and medical
HIV and AIDS is a development issue that calls for social and political action. It is
interventions. Such responses require democracy, pro-people inter-sectoral policies,
Remove pharmaceutical patents that adversely affect availability of generic drugs.
good governance, people's participation and effective communication.They should
be rooted in internationally accepted human rights and humanitarian norms.
We call upon all individuals and organisations to endorse
The special needs of women and children as infected persons, their dependents
and caregivers should be addressed.
and implement the People’s Charter on HIV and AIDS and
join the People’s Health Movement (PHM).
PHM has an active presence in about 100 countries.
In the current context, People's Charter on HIV and AIDS recognises the devastating
impact of war and conflict on health systems and how it amplifies the vulnerabilities
of people to HIV and AIDS.
Largely based on the People’s Charter for Health of the
People’s Health Movement.
People's Charter on HIV and AIDS draws upon perspectives of communities affected
and infected with HIV and AIDS and those vulnerable to the infection. It encourages
Developed through an active participatory process involving
people from various walks of life, including persons living with
HIV and AIDS.
people to develop their own solutions and hold accountable local authorities, national
governments, international organisations and corporations to their promises and
responsibilities.
For more information contact:
g
s'
People's Health Movement Secretariat:
CHC, 367, Jakkasandra 1st Main, 1st Block,
Koramangala, Bangalore - 560 034, India
Tel: +91 80 5128 0009; Fax: +91 80 25525372
Email: secretariat@phmovment.org
www.phmovement.org
n
:oWer Option , pmd
i
f
VISION
i2-
world - a world in which a healthy life for all is a reality; a world that respects,
I
As stated in the People's Charter for Health: ‘Equity, ecologically sustainable
development, social justice and peace are at the heart of our vision of a better
appreciates and celebrates all life and diversity; a world that enables the flowering
of people’s talents and abilities to enrich one another; a world in which people's
voices guide the decisions that shape our lives'.
8/2/2004. 2:42 PM
L_
PERSPECTIVES
4
The AIDS pandemic is one of the greatest humanitarian crises of all times. It has caused
redress these injustices.
death and misery, destroyed families and communities, derailed development and reversed
■_i
SI
Expose links between the spread of HIV and AIDS and the underlying societal
determinants such as poverty, war and displacement, and participate in efforts to
health gains achieved over decades in one stroke. HIV and AIDS is already’wiping out
a generation in Africa.Two decades after it began its onslaught, the disease is still spreading
E3
fast, gaining a firm foothold in all parts of the world.
•
Provide responsible care and quality treatment to persons living with HIV and AIDS.
HIV and AIDS spreads along migration routes charted out by globalised trade. Social
♦
Stop stigma and discrimination in institutions of care and treatment
S
Respect patients' right to dignity and privacy.
4
Follow ethical and regulatory principles in drug trials.
and economic distress due to conflict, war; disasters, skewed international trade and unjust
economic policies make more and more people vulnerable to the infection.
The landmark Alma Ata Declaration of 1978 promised Health for All by 2000 through
Health Professionals and Health Workers
primary health care. Verticalisation. changing economic priorities, invasion of private
Provide adequate preventive measures to avoid transmission of infection m health
interests into political decision-making and a lack of political will led to a total breakdown
care institutions.
of the public health and primary health care systems during the 1980s and 1990s.The
Support People's Health Movement initiatives that address the larger social, political
spread of HIV and AIDS also contributed to the non-achievement of these goals.
and economic issues.
Poverty, hunger and ill health are increasing because of neo-liberal economic policies.
In this context, integrated, adequately-resourced health systems based on primary health
care and public health are urgently required.
Governments
<
Lack of sensitisation and training of health personnel have created negative attitudes
towaids persons living with HIV and AIDS. Such attitudes and practices lead to stigma
and discrimination that impede interventions.
It is essential to ensure that health care is safe and that people undergoing treatment
Develop and strengthen comprehensive approaches based on primary health care
to include HIV and AIDS interventions.
»
Enhance involvement of people and civil society in planning and implementation.
«
Ensure greater involvement of persons living with HIV and AIDS at all levels.
at health care facilities are not exposed to HIV or other infections.
Ensure occupational safety of health workers.
2
Increase access to basic services to people living with HIV and AIDS.
y-,. :
■
Ensure easy, affordable and sustained availability of quality generic ARV and other
A CALL FOR ACTION
People and Social Movements
s
s9
:
a
I
essential drugs.
*
Allocate adequate resources for public health.
Mobilise and strengthen capacities of communities in health promotion, disease
prevention and care.
Implement guidelines for transparent, scientific and ethical clinical trials.
Empower women and youth as key players in HIV interventions.
Make nutritional inputs and psycho-social support part of HIV and AIDS care.
Budd alliances among positive people's networks, women's movements, health and
Develop programmes for life skill education and women's health empo.-. erment.
social activists, trade unions, student groups, academics and other progressive
Intensify the campaign for equitable and universal access to anti-retroviral (ARV)
c
Promote traditional systems of medicine with enough resources.
>
■>
Promote harm reduction policies and programmes for all vulnerable sections including
X
sex workers, drug users, sexual minorities and street children.
treatment through comprehensive primary health care?
&
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a
s
o
Facilitate legal measures and mass campaigns to change" intellectual property rights
Corporates
regimes that escalate drug prices.
Place people above profits.
Oppose policies dictated by multilateral financial and trade institutions that disregard
Make available diagnostic and prognostic tests that are affordable.
people's right to health and health care.
a
:
constituencies.
Ensure the availability of ARV and essential medicines at affordable rates.
I
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2
8J2J7OC
' rrr
Declaration of Alma-Ata
International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September
1978
protect and promote the health of all the people of the world, hereby makes the following
Declaration:
I
The Conference strongly reaffirms that health, which is a state of complete physical, mental
and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental
human right and that the attainment of the highest possible level of health is a most important
world-wide social goal whose realization requires the action of many other social and
economic sectors in addition to the health sector.
II
The existing,gross inequality in the health status of the people particularly between developed
and developing countries as well as within countries is politically, socially and economically
unacceptable and is, therefore, of common concern to all countries.
in
Economic and social development, based on a New International Economic Order, is of basic
importance to the fullest attainment of health for all and to the reduction of the gap between
t e ealth status of the developing and developed countries. The promotion and protection of
the health of the people is essential to sustained economic and social development and
conti ibutes to a better quality of life and to world peace.
i.
IV
The people have the right and duty to participate individually and collectively in the plannine
and implementation df their health care.
i
V
Governments have a responsibility for the health of their people which can be fulfilled only
by the provision of adequate health and social measures. A main social target of governments,
international organizations and the whole world community in the coming decades should be
the attainment by all peoples of the world by the year 2000 of a level of health that will permit
them to lead a socially and economically productive life. Primary health care is the key to
attaining this target as part of development in the spirit of social justice.
VI
Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals and
families in the community through their full participation and at a cost that the community
and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system,
of which it is the central function and main focus, and of the overall social and economic
development of the community. It is the first level of contact of individuals, the family and
na
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community with the national health system bringing health care as close as possible to where
people live and work, and constitutes the first element of a continuing health care process.
VII
Primary health care:
1. reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country and its communities and is based on the application of the
relevant results of social, biomedical and health services research and public health
experience;
2. addresses the main health problems in the community, providing promotive, preventive,
curative and rehabilitative services accordingly;
3. includes at least: education concerning prevailing health problems and the methods of
preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,
including family planning; immunization against the major infectious diseases; prevention
and control of locally endemic diseases; appropriate treatment of common diseases and
injuries; and provision of essential drugs;
4. involves, in addition to the health sector, all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other sectors; and demands the
coordinated efforts of all those sectors;
5. requires and promotes maximum community and individual self-reliance and participation
in the planning, organization, operation and control of primary health care, making fullest
use of local, national and other available resources; and to this end develops through
appropriate education the ability of communities to participate;
6. should be sustained by integrated, functional and mutually supportive referral systems,
leading to the progressive improvement of comprehensive health care for all, and giving
priority to those most in need;
7. relies, at local and referral levels, on health workers, including physicians, nurses,
midwives, auxiliaries and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and technically to work as a health team
and to respond to the expressed health needs of the community.
VIII
All governments should formulate national policies, strategies and plans of action to launch
and sustain primary health care as part of a comprehensive national health system and in
coordination with other sectors. To this end, it will be necessary to exercise political will to
mobilize the country’s resources and to use available external resources rationally.
IX
All countries should cooperate in a spirit of partnership and service to ensure primary health
care for all people since the attainment of health by people in any one country directly
concerns and benefits every other country. In this context the joint WHO/UNICEF report on
1
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primary health care constitutes a solid basis for the further development and operation of
primary health care throughout the world.
t
{
X
An acceptable level of health for all the people of the world by the year 2000 can be attained
through a fuller and better use of the world's resources, a considerable part of which is now
spent on armaments and military conflicts. A genuine policy of independence, peace, detente
and disarmament could and should release additional resources that could well be devoted to
peaceful aims and in particular to the acceleration of social and economic development of
which primary health care, as an essential part, should be allotted its proper share.
The International Conference on Primary Health Care calls for urgent and effective national
and international action to develop and implement primary health care throughout the world
and particularly in developing countries in a spirit of technical cooperation and in keeping
with a New International Economic Order. It urges governments, WHO and UNICEF, and
other international organizations, as well as multilateral and bilateral agencies, non
governmental organizations, funding agencies, all health workers and the whole world
community to support national and international commitment to primary health care and to
channel: increased technical and financial support to it, particularly in developing countries. ‘
The Conference calls on all the aforementioned to collaborate in introducing, developing and
maintaining primary health care in accordance with the spirit and content of this Declaration.
L
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HHR training: 4"’ - 5th Feb 2008
The Framework of Indian Constitution
The Indian Constitution provides a framework for a welfare/socialist pattern of
development. While civil and political rights are enshrined as fundamental rights that are
justiciable, social and economic rights like health, education, livelihoods etc. are
provided for only as directive principles for the State and hence not justiciable. The latter
comes under the domain of planned development, which the State steers through the Five
Year Plans and other development policy initiatives.
The issue of health is situated in the larger context of right to life and right to life with
dignity.
I
Article 21 of the Indian Constitution, a fundamental right reads: “No person shall be
deprived of his life or personal liberty except through procedure established by law.” The
scope of this article has been expanded to explicate the meaning of right to' life. While for
a long time it was interpreted literally as right to exist - right not to be killed. Over the
years it has come to be accepted that life does not only mean animal existence but the life
of a dignified human being with all its concomitant attributes. This would include a
healthy environment and effective health care facilities and such other related but
essential elements.
It has however, to be borne in mind that fundamental rights are <enforceable
f___ ‘_1_ by and large
only against the State. At the moment the fundamental rights prescribes the duty and the
obligations of the State vis a vis the citizens and hence when one is talking about right to
health and health care as a fundamental right it is referring to the State’s obligation and
not the obligation of private players- either individual practitioners or private hospitals or
nursing homes.
‘Right to health’ is inseparable from ‘right to life', and ‘right to medical facilities’ as a
concomitant of ‘right to health’ is also part and parcel of right to life. Life is not mere
existence but a life of dignity, well-being and all that-makes it complete. In a welfare
state, the corresponding duty to the right to health and medical facility lies with the State.
Part 3 of the Constitution prescribes the fundamental rights of the citizens. These rights
are enforceable against the State in a Court of law. This Chapter does not anywhere
categorically state that the right to health or healthcare is a fundamental right. However, it
does prescribe right to life as a fundamental right. It is an expanded meaning given to this
term that has allowed the Courts to prescribe that right to health and health care is a
fundamental right.
Part 4 of the Constitution lists the Directive Principles of State Policy. These are the
principles which should be followed by the State as the guiding principles while enacting
laws and policies but have traditionally been believed not to be enforceable in Courts of
law. A citizen cannot go to Court for enforcing a claim which is purely based on
1
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Directive Principles. The importance of these principles, however lie in the fact that the
in interpreting fundamental rights the Courts can use the Directive Principles so as to
interpret fundamental rights as much in consonance with the Directive Principles as
possible. The obligation of the State to provide health care facilities is set out in the
Directive Principles of State Policy’. The relevant provisions of the Directive Principles
which cast a duty on State to ensure good health for its citizens are:
I
Article 38. State to secure a social order for the promotion of welfare ofpeople1) State shall strive to promote the welfare ofpeople by securing and protecting as
effectively as it may a social order in which justice, social, economic and
political, shall inform all the institutions ofthe national life.
2) State shall, in particular, strive to minimize the inequalities in income, and
endeavour to eliminate inequalities in status, facilities and opportunities, not only
amongst individuals but also amongst groups ofpeople residing in different areas
or engaged in different vocations.
In other words, no person will be deprived of a healthy life because he cannot afford it.
State must provide facilities that an economically better off person can afford out of his
own pocket.
Article 39. Certain principles of policy to be followed by State- The State shall in
particular, direct its policy towards securinge) that health and strength of workers, men and women, and the tender age of children
ate not abused and that citizens are not forced by economic necessity to enter avocations
unsuited to their age or strength;
f) that children are given opportunities and facilities to develop in a healthy manner and
in conditions offreedom and dignity and that childhood and youth are protected against
exploitation and against moral and material abandonment.
Articles 41, 42 and 47 of the Directive Principles1 enshrined in Part IV of the
Constitution provide the basis to evolve right to health and healthcare:
41. Right to work, to education and to public assistance in certain cases: The State shall,
within the limits of its economic capacity and development, make effective provision for
securing the right to work, to education and to public assistance in cases of
unemployment, old age, sickness and disablement, and in other cases of undeserved want.
42. Provision for just and humane conditions of work and maternity relief: The State shall
make provision for securing just and humane conditions of work and for maternity relief.
Ai tide 47. Duty of State to raise the level of nutrition and the standard of living and to
improve public health"The State shall regard the raising of the level of nutrition and the standard of living of
its people and the improvement of public health as among its primary duties and, in
d Jh r
f
II Th ! aWure J"1 attentlVe t0 the,r Ot,'igatiOn t0 implement socio-economic uplift programmes and to ensure
nSnle »« T f d
'
5 h
3 dUty ‘0 3" Clt'ZenS 10 adhere t0 lhat par' ol',lle Constitution which describes the directive
de term ne fte
71 L r
gOvemanae ot the country- Tlle courts ha''e thcrefore been using the directives as an instrument to
determ,ne the extent of pubhc interest m order to limit the extension of fundamental rights. In doing so they have upheld a number of
statutes on the grounds of public interest, which in other circumstances may have been nullified." (De Villiers, 1992).
i
2
18V
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particular, the State shall endeavour to bring about prohibition of the consumption
except for medical purposes of intoxicating drinks and of drugs which are injurious to
health. ”
Expansion of the scope of article 21 and health: Though the explicit recognition ol the
fundamental right, to health should have preceded the fundamental right to good
environment in India right to health as a fundamental right grew as an off shoot of the
environmental litigation. Pollution free environment as a fundamental right presupposes
right to health as a fundamental right. However, the development of jurisprudence in this
branch has been reverse as right to decent environment was recognized first and from
that followed the right to public health, health and health care.
Secondly, the right to health care has also been debated by the courts in the context of
rights of Government employees to receive health care. A number of observations of the
Court concerning the importance of these rights are to be found in cases dealing with
denial or restriction of health care facilities for Government employees.
I
I
While dealing with the issue of fundamental right to health and health care the Courts
have also dealt with specific categories such as under trials, convicts and mentally ill
persons. The Courts have recognized that mere imprisonment will not deprive a person of
right to health and health care.
There are other international laws, treaties and declarations, which'India is a party to and
which have a bearing on right to health. Provisions in most of these also relate to
fundamental rights and directive principles of the Indian Constitution as well afc relate to
many policy initiatives taken within the country.2
Thus social security, social insurance, decent standard of living, and public health
coupled with the policy statements over the years, which in a sense constitutes the
interpretation of these constitutional provisions, and supported by international legal
commitments, form the basis to develop right to health and healthcare in India..The only
legal/constitutional principle missing is the principle of justiciability. In the case of
education the 93rd amendment to the Constitution has provided limited justiciability. With
regard to healthcare there is even a greater need to make such gains because often in the
case of health it is a question of life and death. As stated earlier, for a small part of the
working population right to healthcare through the social security/social insurance route
exists. The fact that this exists shows that for the larger population too it could be worked
out. And that afew people enjoy this privilege is also a sign of discrimination and
inequity, and this violates not only the non-discrimination principle of international law,
but it also violates Article 14 of the constitution, Right to Equality, under the chapter of
Fundamental Rights.
2 For instance the impact of CEDAW, Cairo and Bejing Declarations is closely linked to the formulation of a policy on women and
women’s empowerment, and setting up of the national and state Commissions on Women, the Rashtriya Mahila Kosh and of
formulation of many development programs for women like DWACRA. savings and credit programs etc.. Similarly the various
human rights treaties like those dealing with racial discrimination, torture, civil and political rights etc.and the UNCHR have been
instrumental in India setting up the National and Slate Human Rights Commissions The NHRC has presently set up a separate cell to
monitor ICESCR as also for right to public health
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Basic social services are now being recognised as fundamental rights with the 86lh
amendment in the constitution accepting Education as a fundamental right. Despite the
controversy and problems regarding the actual provisions of the Bill, it is now being
accepted hat essenual social services like education can be enshrined in the fundamental
ng is of the Constitution. This forms an appropriate context to establish the Right to
health care as a constitutionally recognised fundamental right.
The social and economic justification
I
equitable economic growth. The proponents of'economic growth above all' may do well
to heed the words of the Nobel Laureate economist Amartya Sen and the academicactivist Jean Dreze:
Among the different forms of intervention that can contribute to the provision of social
security, the role of health care deserves forceful emphasis ... A Well developed system
of public health is an essential contribution to the fulfilment of social security objectives.
...we have every reason to pay full attention to the importance of human capabilities also
as instruments for economic and social performance. ... Basic education, good health and
other human attainments are not only directly valuable ... these capabilities can also help
m generating economic success of a more standard kind ... ’3
Legal Framework
I
f
Justiciability: With regard to the question of justiciability of international law there is a
problem in India. Like its colonial exploiter Britain, India follows the principle of
dualism. This means that for international law to be applicable in India, it needs to be
separately legislated. Since none of the international human rights treaties have been
incorporated or transformed into domestic laws in India, they thus have only an evocative
significance and may be used by the Courts or petitioners to derive inspiration from them.
(Nariman, 1995) Thus on a number of occasions many of these human right treaties
which India has ratified, have been used by the Indian Courts in conjunction with
fundamental rights. While international law may be invoked, as discussed above, the
absence of justiciability is a major stumbling block. International law has its importance
in providing many principles but in India’s case, as we have seen above, there is
substantial leeway within our own legal framework to evolve the right to health and
healthcare. The emphasis needs to shift to critical principles as laid down in the directive
principles and each of these, like health, education, social security, livelihood, housing
pJean Dreze and Amartya Sen, India: Economic Development and Social Opportunity, Oxford University
Un a judgment on sexual harassment at the work place, in which the CEDAW and Beijing Declaration was invoked, the Supreme
Court outlined this approach as follows - Any international convention not inconsistent with the fundamental rights and in harmony
with its spirit must be read into these provisions to enlarge the meaning and content thereof, to promote the object of the constitutional
guarantee^Vishaka v/s State of Rajasthan, writ petition number 666-70 of 1992. quoted in Toebes, 1998)
4
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!
etc. so that each of these can be separately constituted as independent rights. This is the
only way of bringing right to health and healthcare on the national agenda, and of course
the support of international treaties will have their role in cementing this demand.,
In an important judgement (Paschim Banga Kliet Mazdoor Samity and others v. State of
West Bengal and another, 1996), the Supreme Court of India ruled that “In a welfare state the primary duty of the Government is to secure the welfare of the
people. Providing adequate medical facilities for the people is an essential part of the
obligations undertaken by the Government in a welfare state. ... Article 21 imposes an
obligation on the State to safeguard the right to life of every person. ... The Government
hospitals run by the State and the medical officers employed therein are duty bound to
extend medical assistance for preserving human life. Failure on the part of a
Government hospital to provide timely medical treatment to a person in need of
such treatment results in a violation of his right to life guaranteed under Article 21.
(emphasis added)”
Similarly in the case Bandhua Mukti Morcha v. Union of India and others, 1982
concerning bonded workers, the Supreme Court gave orders interpreting Article 21 as
mandating the right to medical facilities for the workers
Role of Public Interest Litigations In Promoting Right To Health As Fundamental
Right:
There were two developments in the 1980s which led to a marked increase in health
related litigation. First was the establishment of consumer courts which made it cheaper
and speedier to sue doctors and hospitals lor medical negligence and deficiency in
service. Second, the growth of public interest litigation, wider interpretation of right to
life as a fundamental right and one of its off shoots being recognition of health and
health care as a fundamental right.
The Public interest litigation movement in India started in late 1970s. Its foundation is the
enforcement of fundamental rights guaranteed under the Constitution of India. Any
citizen could trigger off the judicial mechanism by claiming violation of fundamental
rights, either of himself or of other individuals or of citizenry at large. Fundamental rights
existed even before late 1970s. The real push for the PIL movement came from an
expanded interpretation of the fundamental right to life which is enshrined in Article 21
of the Constitution. This reads:
“No person shall be deprived of his life or personal liberty except through
procedure established by law. “
Till the 1970s by and large the courts had interpreted ‘life’ literally i.e. right to exist. It
was in late 1970s onwards that an expanded meaning started to be given to the word
life . Over the years it has come to be accepted that life does not only mean merely
animal existence but the life of a dignified human being with all its concomitant
5
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attributes. This has been interpreted to include a
healthy environment and effective health
care facilities.
off shool’of th' '0
“
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6
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Annex 1
Examples of international, regional, and national
instruments relevant to the right to health 1
I
Selected excerpts from international human rights treaties
II
Regional human rights instruments
' III
Selected excerpts from constitutional provisions and national legislation that confirm the
right to health
IV
International instruments relating to specific groups
V
International instruments relating to specific contexts
VI
Selected international conference outcomes, and their follow ups, that relate to the right to
health
VII
Other international documents that provide standards for the right to health
Selected excerpts from international human rights treaties
I
Universal Declaration of Human Rights (UDHR)
• I
Article 25
Everyone has the right to a standard of living adequate for the health and well-being of himself and
1.
his family, including food, clothing, housing and medical care and necessary social services, and the
right to security in the event of unemployment, sickness, disability, widowhood, old age or other
lack of livelihood in circumstances beyond his control.
Motherhood and childhood are entitled to special care and assistance. All children, whether born in
2.
or out of wedlock, shall enjoy the same social protection.
International Covenant on Civil and Political Rights (ICCPR)
Article 6
1.
Every human being has the inherent right to life. This right shall be protected by law. No one shall
be arbitrarily deprived of his life.
Article 7
No one shall Lv.
be subjected to torture- or to cruel, inhumane or degrading treatment or punishment. In
particular, no (one shall be subjected without his free consent to medical or scientific experimentation.
International Covenant on Economic, Social and Cultural Rights (ICESCR)
Article 12
The States Parties to the present Covenant recognize the right of every<one to the enjoyment of the
1.
highest attainable standard of physical and mental health.
The steps to be taken by the States Parties to the present Covenant to achieve the full realization of
2.
this right shall include those necessary for:
(a) The provision for the reduction of the still-birth rate and of infant mortality and for the
healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
(d) The creation of conditions which would assure to all medical services and medical attention
in the event of sickness.
156
tr?
Note: CESCR General Comment 14 on tthe
’ right to the highest attainable standard of health (2000)
provides
the
most
detailed
interpretation
Cfondardc an
i
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: 1 to date of state obligations and internationally accepted
standards and principles arising from the right to health.
H
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International Convention on the Elimination of All Forms of Racial Discrimination
(ICERD)
Article 5
nXeniake t0 prOhibit and J0 eliminate racial discrimination in all its forms and to
guarantee the right of everyone, without distinction as to race, colour, or national
or ethnic origin.
to equality before the law, notably in the enjoyment of the following rights:
(e)
(iv)
The right to public health, medical care, social security and social services
Convention on the Elimination of All Forms of Discrimination against Women (Women's
Convention)
Article 11
1.
States Parties shall take all appropriate measures I
to eliminate discrimination against women in the
field of employment in order to ensure,■ on a basis of equality of
: men and women, the sam'e rights.
in particular:
£
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(\Xu?din^rtlXOcntio°n “oduction,Safety " ""b1"8
“"8 the
Article 12
fieldoSeafthcare intrde' 3PPr°Priate meaSUres to eliminate discrimination against women in the
field of health care in order to ensure.
2.
»««»n d„,„s P^Xn."±"n,"e
■"Vl”s "h"'
“ X.»
Article 14
2.
benefit
-s"”*—"■ ™,.i
“'<l
de„top„«„, .„d, ln
*»“>•
"■’-•xts?iSEsassar
«<”""'Xd^o'n™n fcX" X"S)“SdAW c?'X"“hP'C1“d':CroA'’
Convention against Torture I...C
and Other Cruel, Inhuman or Degrading Treatment or
Punishment (Torture Convention,, or CAT)2
Article 1
p“"»
person information or a confession, punishing
for m/ac'
fr°m b™ “ 3 tKird
suspected of having committed, or intimidatinforrnerH k
H or a third person has committed or is
discrimination of any kind, when such pain ot suffering ^fl“i VPeiS°v °r f°r any reaSOn based on
consent or acquiescence of a public official or other wJ lnfllcted bV or at *e instigation of or with the
157
184
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I
Convention on the Rights of the Child (Children's Convention, or CRC)
Article 24
States Parties recognize the right of the child to the enjoyment of the highest attainable standard of
health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall
strive to ensure that no child is deprived of his or her right of access to such care services.
1.
States Parties shall pursue full implementation of this right and, in particular, shall take appropriate
2.
measures:
(a) To. diminish infant and child mortality;
(b) To ensure the provision of necessary medical assistance and health care to all children with
emphasis on the development of primary health care,
(c) To combat disease and malnutrition, including within the framework of primary health care
through, inter alia, the application of readily available technology and through the provision
of adequate nutritious foods and clean drinking-water, taking into consideration the dangers
and risks of environmental pollution;
(d) To ensure appropriate prenatal and postnatal health care for mothers,
(e) To ensure that all segments of society, in particular parents and children, are
ha™
access to education and are supported in the use of basic knowledge of child health and
nutrition, the advantages of breast-feeding, hygiene and environmental samtation and the
prevention of accidents;
id family planning education and
(f) To develop preventive health care guidance for parents, an<
services.
States Parties shall take all effective and appropriate measures with a view to abolishing traditional
3.
practices prejudicial to the health of children.
States Parties undertake to promote and encourage international cooperation withl a view to
ignized in the present article. In this
achieving progressively the full realization of the right recog
regard, particular account shall be taken of the needs of developing countries.
4.
(2003); and CRC General Comment 3 on HIV/AIDS and the rights of the child (2003).
Regional human rights instruments
II
Inter-American System
.
American Declaration of the Rights and Duties of Man (1948), Article 11;
•
American Convention on Human Rights (1969);
•
healthy environment); and
Punishment and Eradication of Violence Against
Inter-American Convention on the Prevention,
Wompn — 'Convention of Bel£m Do Pard.
African System
.
African Charter on Human and Peoples' Rights (1981), Article 16;
.
African Charter on the Rights and Welfare of tire Child (1990), Article 14;
i
1
158
■
European System
Council of Europe (CoE):
•
European Social Charter (1961), and the Revised Charter, (1996), Article 11,
•
European Convention for the Protection of Human Rights and Fundamental Freedoms (1950) and
its Twelve Protocols (1952-2000) [as amended by Protocol No.llJ;
I
I
European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or
Punishment; and
European Convention on Human Rights and Biomedicine arid its Protocols (1997).
•
•
European Union (EU):
Charter of Fundamental Rights of the European Union (2000)
•
Note: There is no regional human rights system in place in Asia.
Selected excerpts from constitutional provisions and national
legislation that confirm the right to health
III
There are over 60 constitutional provisions which include the right to health or the right to health care, and
over 40 constitutional provisions which include health-related rights, including the right to reproductive
health care, the right of disabled persons to material assistance, and the right to a healthy environment.
The following examples of national constitutional provisions and legislation illustrate how different healthrelated provisions are used to achieve different results.
Constitution of the Republic of South Africa
27(1) Everyone has the right to have access to a health care services, including reproductive health care;
b sufficient food and water; and
I
c social security, including, if they are unable to support themselves and their dependants,
appropriate social assistance.
I
(2)
The state must take reasonable legislative and other measures, within its available
resources, to achieve the progressive realization of each of these rights.
(3)
No one may be refused emergency medical treatment.
24(a) Everyone has the right -to an environment that is not harmful to their health or well-being
Constitution of India
47.
"Duty of the State to raise the level of nutrition and the standard of living and to improve public
health.
The State shall regard the raising of the level of nutrition and tire standard of living of its: people
and the improvement of public health as among its primary duties and, in particular, the State
shall endeavour to bring about prohibition of the consumption except for medicinal purposes of
intoxicating drinks and of drugs which are injurious to health."
from Part IV of Indian Constitution, Directive Principles of State Policy
Canada Health Act
The 1984 Canada Health Act establishes national health services and sets out the basic principles for achieving
the goal of universal health care coverage. In order for the country's provincial health systems to be eligible
for federal funding, five preconditions must be met: comprehensive benefits, universality, accessibility,
portability, and public administration. The Act sets out the following requirements to be met in order for these
conditions to be satisfied:
159
1%
• Comprehensiveness: 'Medically necessary' health care services are to be provided, including
the services of general practitioners and specialists as well as in-patient and out-patient
services. In-patient services of hospitals are to be equipped and staffed to provide care at a
standard level;
• Universality: 100 percent of the population (ie eligible residents) has to be covered in order to
qualify as a'universal plan';
• Accessibility Payment for the cost of insured services must be on uniform terms and conditions
that neither impede nor preclude reasonable access by insured persons, including those with the
lowest incomes;
• Portability: Available benefits will continue to be honoured when residents visit or move
permanently to another province; and
.
• Public administration: Medical plans must be administered and operated on a non-profit basis
by an independent, non-political agency that is accountable to the provincial/territorial minister
of health and government.
International instruments relating to specific groups ’
IV
Racial and ethnic groups
International Covenant on the Elimination of All Forms of Racial Discrimination (1965); ILO
Convention No 169 (concerning Indigenous and Tribal Peoples in Independent Countries,
.
and
Declaration on tire Rights of Persons Belonging to National or Ethnic, Religious and Linguistic
.
Minorities (1992).
Women
•
Convention on the Elimination of All Forms of Discrimination against Women (1979);
•
.
Declaration on the Elimination of Violence against Women (1993),
General Recommendation 14 of the Committee on the Elimination of Discrimination against Women
.
(CEDAW) on female circumcision (1990);
General Recommendation 19 of CEDAW on violence against women (1992); and
.
General Recommendation 24 of CEDAW on women and health (1999).
Children
•
•
Convention on the Rights of the Child (1989);
ILO Convention No 138 (concerning Minimum Age for Admission to Employment, 1973);
•
.
ILO Convention No 182 (the Worst Forms of Child Labour Convention, 1999);
United Nations Standard Minimum Rules for the Administration of Juvenile Justice (1985);
.
United Nations Rules for the Protection of Juveniles Deprived of Their Liberty (1990);
•
.
Declaration on the Rights of the Child (1959),
General Comment 4 on adolescent health and development in the context of the Convention on the
.
Rights of the Child (2003); and
General Comment 3 on HIV / AIDS and the rights of the child (2003).
Migrant workers
•
International Convention on
Their Families (1990).
the Protection of the Rights of All Migrant Workers and Members of
I
160
nt
People with disabilities including mental disabilities
•
Declaration on the Rights of Disabled Persons (1975);
I
•
Standard Rules on the Equalization of Opportunities for Persons with Disabilities (1993);
I
•
Principles for the Protection of Persons with Mental Illness and the Improvement of Mental
Healthcare (1991);
•
CESCR General Comment 5 on persons with disabilities (1994); and
•
Human Rights Committee General Comment 21 (1992).
Older people
•
United Nations Principles for Older Persons (1991); and
•
CESCR General Comment 6 on the economic, social and cultural rights of older persons (1995).
Refugees
•
Convention relating to the Status of Refugees (1951).
International instruments relating to specific contexts5
V
Armed conflict
The Geneva Convention for the Amelioration of the Condition of Wounded and Sick'in Armed
Forces in the Field (1949);
The Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked
Members of the Armed Forces at Sea (1949);
The Geneva Convention relative to the Treatment of Prisoners of War (1949);
The Geneva Convention relative to the Protection of Civilian Persons in Times of War (1949);
Additional Protocol 1 to the Geneva Conventions relating to the Protection of Victims in
International Armed Conflict (1977);
Additional Protocol II to the Geneva Conventions relating to the Protection of Victims of Non
International Armed Conflicts (1977);
Declaration on the Protection of Women and Children in Emergency and Armed Conflict (1974); and
Protocol on Prohibitions or Restrictions on the Use of Mines (1980).
Occupational health and safety
•
ILO Convention No. 155 (Occupational Health and Safety Convention, 1981);
•
ILO Convention No. 148 (Working Environment Convention, 1977); and
•
several other ILO Conventions (eg Conventions Nos. 130, 152, 161, 164, 167, 170, 171, 176, 177 and
184).
I
Environmental health
Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their
Disposal (1989);
I
Code of Practice on the International Transboundary Movement of Radioactive Waste (1990); and
I
Convention on Nuclear Safety (1994).
I
I
161
f
J.
Administration of Justice '
.
International Covenant on Civil and Political Rights (ICCPR, 1966);
.
Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or
.
.
(CAT, 1984);
Standard Minimum Rules for the Treatment of Prisoners (1955);
Body of Principles for the Protection of All Persons under any Form of Detention or Imprisonment
.
(1988);
Code of Conduct for Law Enforcement Officials (1979); and
Punishment
Treatment or Punishment (1982).
Development
Declaration on the Right to Development (1986).
Research, experimentation and genetics
•
Niirnberg Code (1947);
•
,C(TR;
Universal Declaration on the Human Genome and Human Kights (I W);
.
Declaration on the Use of Scientific and Technical Progress in the Interests of Peace and for the
.
Benefits of Mankind (1975); and
General Comment 20 of the Human Rights Committee (1992).
Data Protection
.
Guidelines for the Regulation of Computerized Personal Data Files (1990); and
.
General Comment 16 of the Human Rights Committee (1988).
Nutritional Health
Universal Declaration on the Eradication of Hunger
•
I
i
and Malnutrition (1974).
Selected international conference outcomes, and their follow
VI
ups, that relate to the right to health 6
Johannesburg Declaration and Plan of Implementation of the
World Summit for Sustainable
o<
DedmM" ."d
WotU
Pto o( Adto » A8.,n8
on
" — rZX
A-.
Discrimination, Xenophobia and Related Intolerance (2001),
.
United Nations Millennium Declaration,
by the Un’te
"Millennium Assembly of the United Nation.
162
General Assembly
Beijing Declaration and Platform for Action of the Fourth World Conference on Women (1995) and
its follow-up, Beijing Plus 5 (2000)
•
Programme of Action of the International Conference on
its follow-up, ICPD+5 (1999)
Population and Development (1994) and
of the World Food Summit: Five Years Later,
International Alliance Against Hunger (2002);
Istanbul Declaration and the Habitat Agenda of the Second Unitec'
qptthmpnk (Habitat II) (1996), and the Declaration on Cities and Other Human b
New Millenium of the Special Session of the General Assembly for an overall review and appraisa
•
.
of the implementation of the Habitat Agenda (2001),
Copenhagen Declaration on Social Development and Programme of Action of the World Summit for
.
Social Development (1995) and its follow-up, Copenl.agen Plus 5 (2000);
Vienna Declaration and Programme of Action adopted by the World Conference on Human Rights
(1993);
Rio Declaration on Environment and Development and Agenda 21 of the United Nations
Conference on Environment and Development (1992); and
Stockholm Declaration of the United Nations Conference on the Human Environment (1972).
•
•
Other international documents that provide standards for the
VII
right to health
The following are examples of legally non-binding documents that elaborate detailed and targeted
principles and norms on the right to health. As such, they are complementary to legal instruments by ad
g
meaning and substantive content to specific aspects of the right to health.
•
Declaration of Alma Alta from the International Conference on Primary Health Care (1978),
•
World Health Organization Action Programme on Essential Drugs;
•
•
World Medical Association Declaration of Helsinki (1964);
Commonwealth Medical Association Guiding Principles on Medical Ethics and Human Rights;
•
Framework Convention on Tobacco Control (2003),
•
Principles relating to the status of national institutions (Taris Principles 1992); and
.
International Guidelines on HIV/AIDS and Human Rights (1997).
Notes
health. For
further
Annex 1 does not provide a comprehensive list of instruments that are relevant
relevant to
to the
the right
right to
to health,
tor termer
standards, see references: WHO. 25 Questions and answers on health and human rights. Health and Huma
g .
1
non-governmental organizations, and professional associations. Dordrecht, The Netherlands. Nijhoff, 1998.
2
3
4
It should be noted that the so-called 'United Nations Code of Medical Ethics' ie Principles of Medical Ethics
to the Role of Health' Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Tortu c
and other Cruel, Inhumane or Degrading Treatment or Punishment (1962), is equivocal on the etmcaI p
health professionals participating in the carrying out of sentences of capital or corporal Pumshmen1 Propedy
constituted courts of law, including judicial amputations (see chapter 12 and Administration of Justice above).
According to preliminary findings from a study commissioned by the WHO from the International Commission of
Jurists. 1CJ, Right to Health Database, Preliminary Proposal, 2002, as cited in: Hunt I. Repor o
e pe i<
Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and menta
health. E/CN.4/2003/58. p 8.
Reproduced, with minor adaptation, from: Hunt P. Report of tlie Special Rapporteur on the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health. E/CN.4/2003/58. Annex I, Section B, p .
5
Reproduced, with minor adaptation, from: Hunt P. Ibid:Annex I, Section C, p 29.
6
Reproduced, with minor adaptation, from: Hunt P. Ibid:Annex 1, Section D, p 30-31.
I
I.
I
i
163
I
Annex 2
I
Examples of global goals, targets and indicators
relevant to health
Annex 1 highlights three examples of global goals, targets and indicators that can be relevant for monitoring
implementation of the right to health. The examples include:
I
Millennium Development goals (MDGs), targets and indicators;
II
World Health Organization (WHO) reproductive health indicators for global monitoring;
III
International Conference on Population and Development (ICPD) Programme of Action
(PoA) 20-year goals; and Key Actions for the Further Implementation of the Programme of
Action of the ICPD (ICPD+5).
I
Millennium Development goals, targets and indicators 1
Goal 1 ,
Eradicate extreme poverty and hunger
Target 1
;
Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day
Indicators
1
Proportion of population below $1 (PPP) per day (World Bank)2
2
Poverty gap ratio [incidence x depth of poverty] (World Bank)
3
Share of poorest quintile in national consumption (World Bank)
Target 2
Halve, between 1990 and 2015, the proportion of people who suffer from hunger
Ii
Indicators
4
Prevalence of underweight children under five years of age (UNICEF-WHO)
5
Proportion of population below minimum level of dietary energy consumption (FAO)
Goal 2
Achieve universal primary education
Target 3
Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of
primary schooling
Indicators
6
Net enrolment ratio in primary education (UNESCO)
7
Proportion of pupils starting grade I who reach grade 5 (UNESCO) '
8
Literacy rate of 15-24 year-olds (UNESCO)
Goal 3
Promote gender equality and empower women
Target 4
Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of
education no later than 2015 .
164
Indicators
Ratio of girls to boys in primary, secondary and tertiary education (UNESCO)
9
10
Ratio of literate women to men, 15-24 years old (UNESCO)
11
Share of women in wage employment in the non-agricultural sector (ILO)
12
Proportion of seats held by women in national parliament (IPU)
Reduce child mortality
Goal 4
Target 5
Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
Indicators
13
Under-five mortality rate (UNICEF-WHO)
14
Infant mortality rate (UNICEF-WHO)
Proportion of 1 year-old children immunized against measles (UNICEF-WHO)
15
Goal 5
Improve maternal health
Target 6
Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
Indicators
16
Maternal mortality ratio (UNICEF-WHO)
17
Proportion of births attended by skilled health personnel (UNICEF-WHO)
Goal 6
Combat HIV/AIDS, malaria and other diseases
Target 7
Have halted by 2015 and begun to reverse the spread of HIV / AIDS
Indicators
18
HIV prevalence among pregnant women aged 15-24 years (UNAIDS-WHO-UNICEF)
19
Condom use rate of the contraceptive prevalence rate (UN Population Division)4
19a
Condom use at last high-risk sex (UNICEF-WHO)
19b
Percentage of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS
(UNICEF-WHO)5
19c
Contraceptive prevalence rate (UN Population Division)
20
Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years
(UNICEF-UNAIDS-WHO)
Target 8
Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
Indicators
21
Prevalence and death rates associated with malaria (WHO)
22
Proportion of population in malaria-risk areas using effective malaria prevention and treatment
measures (UNICEF-WHO)6
23
Prevalence and death rates associated with tuberculosis (WHO)
165
I
Proportion of tuberculosis cases detected and cured under DOTS (internationally recommended TB
control strategy) (WHO)
24
Ensure environmental sustainability
Goal 7
Target 9
Integrate the principles of sustainable development into country policies and programmes and reverse the
loss of environmental resources
Indicators
25
Proportion of land area covered by forest (FAO)
26
Ratio of area protected to maintain biological diversity to surface area (UNEP-WCMC)
Energy use (kg oil equivalent) per $1 GDP (PPP) (IEA, World Bank)
Carbon dioxide emissions per capita (UNFCCC, UNSD) and consumption of ozone-depleting CFCs
27
28
(ODP tons) (UNEP-Ozone Secretariat)
Proportion of population using solid fuels (WHO)
29
Target 10
I lalve, by 2015, the proportion of people without sustainable access to safe drinking water and sanitation
Indicators
30
Proportion of population with sustainable access to an improved water source, urban and rural
(UNICEF-WHO)
Proportion of population with access to improved sanitation, urban and
31
rural (UNICEF-WHO)
Target 11
By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers
Indicators
I
I
32
Proportion of households with access to secure tenure (UN-HABITAT)
Goal 8
Develop a global partnership for development
Indicators for targets 12-15 are given below in a combined list.
Target 12
Develop further an open, rule-based, predictable, non-discriminatory trading and financial system.
Includes a commitment to good governance, development and poverty reduction - both nationally and
internationally
Target 13
Address the special needs of the least developed countries.
ODA for countries committed to poverty reduction
of the twenty-second special session of the General Assembly)
166
Target 15
Deal comprehensively with the debt problems of developing countries through national and international
measures in order to make debt sustainable in the long term
Some of the indicators listed below are monitored separately for the least developed countries (LDCs), Africa,
landlocked developing countries (LLDCs) and small island developing States (SIDS)
Indicators
Official development assistance (ODA)
I
33
Net ODA, total and to LDCs, as percentage of OECD/Development Assistance Committee (DAC)
donors' gross national income (GNI)(OECD)
34
Proportion of total bilateral, sector-allocable ODA of OECD/DAC donors to basic social services
(basic education, primary health care, nutrition, safe water and sanitation) (OECD)
35
Proportion of bilateral ODA of OECD/DAC donors that is untied (OECD)
36
ODA received in landlocked developing countries as a proportion of their GNIs (OECD)
37
ODA received in small island developing States as proportion of their GNIs (OECD)
Market access
38
39
Proportion of total developed country imports (by value and excluding arms) from developing
countries and from LDCs, admitted free of duty (UNCTAD, WTO, WB)
Average tariffs imposed by developed countries on agricultural products and textiles arid clothing
from developing countries (UNCTAD, WTO, WB)
40
Agricultural support estimate for OECD countries as percentage of their GDP (OECD)
41
Proportion of ODA provided to help build trade capacity (OECD, WTO)
Debt sustain ability
>
.*
;
42
Total number of countries that have reached their Heavily Indebted Poor Countries Initiative (HIPC)
decision points and number that have reached their HIPC completion points (cumulative)' (IMF World Bank)
43
Debt relief committed under HIPC initiative (IMF-World Bank)
44
Debt service as a percentage of exports of goods and services (IMF-World Bank)
Target 16
In cooperation with developing countries, develop and implement strategies for decent and productive work
for youth
Indicators
45
Unemployment rate of young people aged 15-24 years, each sex and total (ILO)7
Target 17
In cooperation with pharmaceutical companies, provide access to affordable essential dings in developing
countries
Indicators
46
Proportion of population with access to affordable essential drugs on a sustainable basis (WHO)
Target 18
In cooperation with the private sector, make available the benefits of new technologies, especially information
and communications
Indicators
47
Telephone lines and cellular subscribers per 100 population (ITU)
48
Personal computers in use per 100 population and Internet users per 100 population (ITU)
*167
f
WHO reproductive health indicators for global monitoring
jj
ICPD and ICPD+5 reproductive health goals and the 17 indicators8
Table- ICPD and-ICPD+5 benchmarks and the relevant reproductive health indicator
from the interagency's short list which can be used (some as a proxy) to measure progress
towards the global target
I
Global Indicator
1. Total fertility rate
ICPD goal
While the Programme of Action does not quantify goals for population growth,
structure and distribution, it reflects the view that an early stabilisation of
world population would make a crucial contribution to realizing the
overarching objective of sustainable development
ICPD+5 ,21st Special Session, Agenda item 8, §7
2. Contraceptive
prevalence
1
Assist couples and individuals to achieve their reproductive goals and give
them the full opportunity to exercise the right to have children by choice
ICPD Principle 8, 7.12, 7.14(c), 7.16
Provide universal access to a full range of safe and effective family planning
health care
care
methods, as part of comprehensive sexual and reproductive health
ICPD 7.2, 7.4, 7.6, 7.14(a)
Bv 2005 60 percent of primary health care and
and family
family planning
planning facilities should
snouiu
offer the widest achievable range of safe and effective family planning methods
ICPD+5 ,21st Special Session, Agenda item 8, §53
3. Maternal Mortality
Ratio
Countries should strive to effect significant reductions in maternal morbidity
and mortality by the year 2015: a reduction in maternal mortality by one half
of the 1990 levels by the year 2000 and a further one half by 2015. Disparities in
maternal mortality within and between countries, socio-economic and ethnic
groups should be narrowed
ICPD 8.21
4. Antenatal care
coverage
5 Births attended by
skilled health
personnel
Expand the provision of maternal health services in the context of primary
health care. These services should offer prenatal care and counselling, with
special emphasis on detecting and managing high-risk pregnancies
ICPD S.17, 8.22
All births should be attended by trained persons
ICPD 8.22
AU countries should continue their efforts so that globally, by 2005 at least 80
percent of all births should be assisted by skilled attendants, by 2010, 85
percent, and by 2015, 90 percent
ICPD+5 ,21st Special Session, Agenda item 8, §64
6. Availability of basic
essential obstetric
care
Expand the provision of maternal health services in the context of primary
hellth care. These services should offer adequate delivery assistance and
provision for obstetric emergencies
ICPD 8.22 .
I
I
168
7. Availability of
comprehensive
essential obstetric
care
By 2005, 60 percent of primary health care and family planning facilities should
offer, directly or through referral, essential obstetric care
ICPD+5 ,21st Special Session, Agenda item 8, §53
8. Perinatal mortality
rate
Within the framework of primary health care, extend integrated reproductive
health care and child health services, including safe motherhood, child survival
programmes and family planing services, particularly to the most vulnerable
and under-served groups
ICPD 8.17
9 Low birth weight
prevalence
To improve the health and nutritional status of women, especially of pregnant
women, and of infants and children
Interventions to reduce low birth-weight should include the promotion of
maternal nutrition and the promotion of longer intervals between births
ICPD 8.15(b), 8.17, 8.20 (b)
10 Positive syphilis
serology prevalence
in pregnant women
Prevent and reduce the incidence of, and provide treatment for, sexually
transmitted diseases, including HIV/AIDS
ICPD 7.29
By 2005, 60 percent of primary health care and family planning facilities should
offer prevention and management of reproductive ttract infections, including
STDs and barrier methods to prevent infection
ICPD+5 ,21st Special Session, Agenda item 8, §53
11 Prevalence of
anaemia in women
Countries should implement special programmes on the nutritional needs of
women of childbearing age, and give particular attention to the prevention and
management of nutritional anaemia
ICPD 8.24
12 Percentage of
obstetric and
gynaecological
admissions owing to
abortion
Women should have access to quality services for the management of
complications arising from abortions
ICPD 8.25
f
13 Reported prevalence
of women with FGM
Countries should take steps to eliminate violence against women
Governments should prohibit female genital mutilation/cutting wherever it
exists and give vigorous support to efforts among non-governmental
organizations and religious institutions to eliminate such practices ,
ICPD 4.4(e), 4.22
'
i
14 Prevalence of
infertility in women
Prevent and reduce the incidence of, and provide treatment for, sexually
transmitted diseases, including HIV/AIDS, and the complications of sexually
transmitted diseases such as infertility, with special attention to girls and
women
ICPD 7.29
By 2005, 60 percent of primary health care and family planning facilities should
offer prevention and management of reproductive tract infections, including
STDs and barrier methods to prevent infection
ICPD+5 ,21st Special Session, Agenda item 8, §53
169
Zoo
I
I
I
Prevent and reduce the incidence of, and provide treatment for, sexu
15 Reported incidence
of urethritis in men
y
transmitted diseases, including HIV/AIDS
ICPD 7.29
STDs and barrier methods to prevent infection
ICPD+5 ,21st Special Session, Agenda item 8, §53
I
16 HIV prevalence in
pregnant women
HIV infection rates in persons 15-24 years of age should be reduced by 25
«((•««!
»y 2005 onb by 23 p.,«« sWy by
1CPD+5 ,21st Special Session, Agenda item 8, §70
17 Knowledge of HIVrelated prevention
practices
'
------ 1 and women, aged 15-24, should have
By 2005 at least 90 percent of young men
•
SS - »’>» ”““»y •• b=v«lop «. »<=
.
/•
•*____
-J « •
♦■I
OYlfl
JCPD+5 ,21st Special Session, Agenda item 8, §70
Definitions
I
'
T»'"' I'"""''
2
Contraceptive prevalence (any method)
.......
Percentage of women of reproductive age who
...... .
.X
are using (or whose partner is using) a contraceptive
method** at a particular point in time.
at risk of pregnancy, i.e. sexually
.
Women of reproductive age in this indicator refers to all ~ aged 15-49, who are
“^“ci^^l
“
method.
Maternal mortality ratio
3
The number of maternal deaths per 100 000 live births.
—
5
attendants are excluded.
BiMs MM by >H“'d bnsUb P«s°M
Ms —1 by — ta'"'
Percentage
attendants).
.
■
attendants are excluded.
Availability of basic essential obstetric care
6
1
1
i
I
t
"
'“'“‘""S
170
untrained traditional birth
sons with midwifery skills who can
7
Availability of comprehensive essential obstetric care
Number of facilities with functioning comprehensive essential obstetric care* per 500 000 population.
Comprehensive essential obstetric care should include basic essential obstetric care plus surgery, anaesthesia and
blood transfusion.
*
8
Perinatal mortality rate
Number of perinatal deaths* per 1000 total births.
★
Deaths occurring during late pregnancy (at 22 completed weeks gestation and over), during
childbirth and up to seven completed days of life.
9
Low birth weight prevalence
Percentage of live births that weigh less than 2500 g.
10
Positive syphilis serology prevalence in pregnant women
Percentage of pregnant women (15—24) attending antenatal clinics, whose blood has been screened for
syphilis, with positive serology for syphilis.
11
Prevalence of anaemia in women
Percentage of women of reproductive age (15-49) screened for haemoglobin levels with levels below 110 g/1
for pregnant women and below 120 g/1 for non-pregnant women.
12
Percentage of obstetric and gynaecological admissions owing to abortion
Percentage of all cases admitted to service delivery points providing in-patient obstetric and gynaecological
services, which are due to abortion (spontaneous and induced, but excluding planned termination of
pregnancy).
13
I
Reported prevalence of women with PGM
Percentage of women interviewed in a community survey, reporting to have undergone FGf4.
14
Prevalence of infertility in women
Percentage of women of reproductive age (15-49) at risk of pregnancy (not pregnant, sexually active, noncontracepting and non-lactating) who report trying for a pregnancy for two years or more.
15
Reported incidence of urethritis in men
Percentage of men (15-49) interviewed in a community survey, reporting at least one episode of urethritis in
the last 12 months.
16
HIV prevalence in pregnant women
Percentage of pregnant women (15-24) attending antenatal clinics, whose blood has been screened for HIV,
who are sero-positive for HIV.
17
Knowledge of HIV-related prevention practices
The percentage of all respondents who correctly identify all three major ways of preventing the sexual
transmission of HIV and who reject three major misconceptions about HIV transmission or prevention.
III
International Conference on Population and Development
(ICPD) Programme of Action (PoA) 20-year goals 9
1
Universal Education
"Beyond the achievement of the goal of universal primary education in all countries before the year 2015, all
countries are urged to ensure the widest and earliest possible access by girls and women to secondary and
higher levels of education, as well as to vocational education and technical training, bearing in mind the need
to improve the quality and relevance of that education." [para. 4.18]
171
ZoX
I
1
Reduction of Infant and Child Mortality
2
"... Countries should strive to reduce their infant and under-five mortality rates by one third, or to 50 and 70
per 1,000 live births, respectively, whichever is less, by the year 2000, with appropriate adaptation to the
particular situation of each country. By 2005, countries with intermediate mortality levels should aim to
achieve an infant mortality rate below 50 deaths per 1,000 live births and an under-five mortality rate below
60 deaths per 1,000 live births. By 2015, all countries should aim to achieve an infant mortality rate below 35
per 1,000 live births and an under-five mortality rate below 45 per 1,000. Countries that achieve these levels
earlier should strive to lower them further." [para. 8.16]
3
Reduction of Maternal Mortality
"Countries should strive to effect significant reductions in maternal mortality by the year 2015: a reduction in
maternal mortality by one half of the 1990 levels by the year 2000 and a further one half by 2015. The
realization of these goals will have different implications for countries with different 1990 levels of maternal
mortality. Countries with intermediate levels of mortality should aim to achieve by the year 2005 a maternal
mortality rate below 100 per 100,000 live births and by the year 2015 a maternal mortality rate below 60 per
100,000 live births. Countries with the highest levels of maternal mortality should aim to achieve by 2005 a
maternal mortality rate below 125 per 100,000 live births and by 2015 a maternal mortality rate below 75 per
100,000 live births. However, all countries should reduce maternal morbidity and mortality to levels where
they no longer constitute a public health problem. Disparities in maternal mortality within countries and
between geographical regions, socio-economic and ethnic groups should be narrowed." [para. 8.211
4
Access to Reproductive and Sexual Health Services Including Family Planning
"All countries should strive to make accessible through the primary health-care system, reproductive health
to all individuals of appropriate ages as soon as possible and no later than the year 2015. Reproductive health
care in the context of primary health care should, inter alia, include: family-planning counselling, information,
education; communication and services; education and services for pre-natal care, safe delivery and post-natal
care; prevention and appropriate treatment of infertility; abortion as specified in paragraph 8.25, including
prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract
infections; sexually transmitted diseases and other reproductive health conditions; and information,
education and counselling, as appropriate, on human sexuality, reproductive health and responsible
parenthood. Referral for family-planning services and further diagnosis and treatment for complications of
pregnancy, delivery and abortion, infertility, reproductive tract infections, breast cancer and cancers of the
reproductive system, sexually transmitted diseases, including HIV/AIDS should always be available, as
required. Active discouragement of harmful practices, such as female genital mutilation, should also be an
integral component of primary health care, including reproductive health-care programmes." [para. 7.6]
The United Nations Population Fund (UNFPA) and WHO are both committed to the achievement of
the ICPD goal that "All countries should strive to make accessible through the primary health care
system, reproductive health to all individuals of appropriate ages as soon as possible and no later than
the year 2015". At a WHO/UNFPA technical consultation, held in December 2003 it was agreed that the
following indicators be used to achieve this goal:10
• percentage of births attended by skilled health personnel;
• contraceptive prevalence;
• knowledge of HIV-related prevention practices; and
• percentage of men aged 15-49 reporting receipt of treatment for urethral discharge.
Key Actions for the Further Implementation of the Programme of Action of
the ICPD — ICPD+5 11
In 1999, the UN General Assembly convened a special session to review progress towards meeting the ICPD
goals. After reviewing the topics highlighted in the ICPD PoA, the special session (known as ICPD+5) agreed
on a new set of benchmarks in four areas:
172
M
I
Education and literacy
y
.
"Governments and civil society, with the assistance of
possible, and in any case before 2015, meet the^Con
access to primary
tiucation by 2005; and strive to ensure that by
XS
S3.—- >» •* “internatio
« nal community,
c“p“d
with an estimated 85 per cent in 2000." [para. 34]
"Governments, in particular of developing countries, wi h thewomen and irls b 2005,
should: ... Reduce the rate of illiteracy of women and men, at least halving
compared with the rate in 1990." [para. 35 (c)[
Reproductive health care and unmet need for contraception
2
Janntag
"... Governments should strive to ensure that by 2015
able to provide, directly or through referral, the widest achievable^
of reproductive tract
and contraceptive methods; essential obstetric c , P
methods (such§as male and female condoms
"Where there is a gap between contraceptive use and the Pr0P0'
I
percent bK2005, 75 per
“fete
legitimately the subject of government development strategies, shoul L
P
providers in the form of targets or quotas for the recruitment of clients, [para. 58]
3
Maternal mortality reduction
"By 2005, where the maternal mortality rate is very high, at least 40 per cent of all births shou!d be aM by
I
skilled attendants, by 2010, 85 per cent, and by 2015, 90 per cent. [para. 64]
4
HIV/AIDS
■Government., with
!~m UNAIDS .nd donom, .hould b, 20®.
.nd by 20>0 et lee.t OS pet cent, o youns.men .nd—“ [X ,2 vnlner.bib.y to HIV
I
I
education and services necessary to dey p
mpfunds such as female and male condoms, voluntary
infection. Services should include access to preven iv
benchmark indicator HIV infection rates in
testing, counselling and follow-up^ Governments should use as a
th/
is reduced
X "valence[n fhi. fpe gtonp i.
reduced globally by 25 per cent." [para. 70]
Notes
1
2
United Nations Millennium Development Goals (MDGs). Available at http: / / www.un.org/milleiuiiumgoals/.
For monitoring country poverty trends, indicators based on national poverty lines should be used, where available.
3
An alternative indicator under development is "primary completion rate .
4
Amuyg cvnlmeepllve melhods
5
reject the two most common local misconceptions about .HIV
person can transmit HIV. However, since there are curren y
.
'
ber of surv
t0 be able t0 calculate
. WHO produCed two proxy indicators
women and men 15-24 who know a healthy-looking person can transmit HI .
173
109
I
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I
6
Prevention to be measured by the percentage of children under 5 sleeping under insecticide-treated bednetstreatment to be measured by percentage of children under 5 who are appropriately treated.
7
An improved measure of the target for future years is under development by the International Labour Organization
8
World Health Organization. Reproductive health indicators for global monitoring. Report of the second interagency
meeting.
Geneva:
2001.
WHO/RHR/O.1.19. • Available
at
http://www.who.int/reproductivehealth/pages_resources/listing_global_mtg.en.html.
9
Programme of Action of the International Conference on Population and Development; Cairo, 1994.
A/CONE171/13. Available at http://www.unfpa.org/icpd/docs/.
10
World Health Organization. Measuring Access to Reproductive Health Services: Summary Report of a
WHO/UNFPA Technical Consultation 2-3 December 2003. Geneva: 2004. WHO/RHR/04.07. Available at
http:// www.who.int/reproductive-health/pages_resources/listing_global_mtg.en.html.
11
United Nations General Assembly. ICPD+5: Key Actions for the Further Implementation of the ICPD Programme of
Action. New York: 1999. A/RES/S-21/2. Available at http://www.unfpa.org/icpd/docs/.
I
I
174
Orientation/Training Program on “Health as a Human Right towards realizing Health for AH”
Session 5 Towards Realizing Health As A Human Right
I
Community Health Cell, Bangalore
r
!
The Right to Health Care is a Basic Human Right!
Towards attaining the Right to Health Care...
The Government of India has been unable to fulfill it’s commitment of ‘Health for All by 2000 A.D.’ till
now. In fact, primary health care services are becoming more and more difficult to obtain especially
for people living in urban slums, villages or remote tribal regions. The condition of government
hospitals is worsening day by day. Nowadays, in most of the government hospitals there is
inadequate staff, the supply of medicines is insufficient and the infrastructure is also inadequate. The
facilities for safe deliveries or abortions are also very inadequate. Given the fact that women do not
even get adequate treatment for minor illnesses such as anaemia, services for problems such as the
health effects of domestic violence remain almost completely unavailable. At the village level, there is
no resident health care provider to treat illnesses or implement preventive measures. All hospitals are
located in cities, and here too public hospitals are increasingly starved of funds and facilities. Thus
there is lack of availability of government health care services on one hand and the exorbitant cost of
private health services on the other. This often leaves common people in rural areas with no other
option but to resort to treatment from quack doctors who often practice irrationally. Thus most of the
population is being deprived of the basic Right to Health Care, which is essential for healthy living.
The Indian Constitution has granted the ‘Right to Life’ as a basic human right to every citizen of India
under article 21. In article 47 of the Directive Principles of the Indian Constitution, the Government’s
responsibility concerning public health has also been laid down. Yet the Government is backtracking
from fulfilling this responsibility. This is obvious from the fact that the Government’s proportion of
expenditure on public health services has been declining every successive year.
What can be done in the near future to establish the Right to Health Care?
The year 2003 was the silver jubilee year of the ‘Health for All’ declaration. On this occasion, Jan
Swasthya Abhiyan launched a nationwide campaign to establish the Right to Health Care as a basic
human right. Some of the following activities are being taken up as part of this campaign:
•
•
•
•
Documentation of individual case studies involving denial of health care. Information is being
collected in a specific format with the help of questionnaires. The cases where denial of health
services has led to the loss of life, physical damage or severe financial loss of the patient are
being emphasised. These case studies will be presented to the National Human Rights
Commission. It is hoped that they would help us to depict the real status of provision of the
primary health services by the government and strengthen our demand for improving public
health services as well as help us in dialoguing with the public health system.
Similarly, situations of structural denial of health care, where Primary Health Centres,
Community Health Centres or public hospitals are regularly denying basic health services to
people are being documented. Questionnaires have been prepared to help in such
documentation, based on which the demand for adequate services and facilities may be raised.
Jan Suriwais on the Right to Health Care are being organised at the local, district and state level.
JSA linked organisations can organise such Jan Sunwais to highlight the state of public health
services, and instances of denial of health care / structural denial of health care can be presented
in these programmes.
The National Human Rights Commission, in collaboration with Jan Swasthya Abhiyan, is
organising Public Hearings on Health and Human Rights in various regions of the country from
mid-2004 onwards. These regional hearings would be followed by a national public hearing. JSA
linked organizations and individuals can present case studies during these public hearings and
ask for effective action by state health authorities and investigation by the NHRC.
These are some of the steps being planned to move towards establishing the Right to Health Care.
Let us join this campaign and strengthen the movement to achieve health care and Health for All!
Jan Swasthya Abhiyan - People’s Health Movement India
For more information visit www.phmovement.org/india or contact:
Jan Swasthya Abhiyan Secretariat, Address: C/o CEHAT ,3&41 Aman Terrace, Plot no.140, Dhahanukar Colony,
Kothrud, Pune-411029 India; Phone: + 91-20-25451413/25452325; E-mail: cehatpun@vsnl.com
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Z©8
Right to Health Care Campaign - A Campaign towards revitalisation of
Public Health Systems in Karnataka
W )
Ji
- A^proposallfor the Revitalisation of Primary Health Centers (thereby
accessibley-affordahle and available primary health care-in Karnataka A
1.0
Background
India is independent of colonial rule for sixty years, but the Indian State has failed to
provide its citizens the basic requirements like food security, health care, housing and
education, which are the basis for reasonable human existence. Due to rampant poverty
and lack of social equity large sections of population have been denied adequate
nutrition, clean drinking water and sanitation, basic education, good quality housing and
a healthy environment, which are all prerequisites for health. A highly inequitable health
system has denied quality health care to all those who cannot afford it.
The first National Health Policy (NHP) of 1983 made its motto ‘Health Care for All by
2000’ which has not happened, while the subsequent National Health Policy 2002
welcomes the participation of the private sector in all areas of health activities thus in a
sense endorsing inequity. The failure of National Health Policies to introduce social
justice and equity has precipitated the issue of the need for a comprehensive legislative
framework to ensure all peoples the right to a healthy life. Thus there is an urgent need
for the promulgation of a comprehensive legislative framework, on Right to Health Care
that would be the prelude to an enforceable fundamental right to Health Care, with
Universal Access to health care as the ultimate aim.
Characteristics of the Current Health Scenario
The National Health Policy 2002 clearly acknowledges that the public health care system
grossly falls short of gross requirements and is functioning in a far from satisfactory
manner. That morbidity and mortality due to easily curable diseases continues to be
unacceptably high, and that resource allocations are generally insufficient are also spelt
out in the policy document
Ii
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Increasing private health sector expenditure vs. shrinking public health expenditure
Public spending on health care in India is as low as 0.9% of the Gross Domestic Product
• (GDP) in contrast to a total health expenditure of 5% of GDP, making public health
expenditure a mere 17% of total health spending in the country. Decreasing public health
expenditure has adversely affected the health outcomes. In India, the under-five mortality
rate is 95 per 1000 whereas Sri Lanka has only 3% of GDP is the total health expenditure,
the und,er-5 mortality is only 19 per 1000. This difference is due to the fact that in Sri
Lanka public health expenditure accounts for as much as 45.4% of total health
expenditure.
I.
India has one of the most privatised health systems in the world, denying the poor access
to even basic health care. Across the country the unregulated growth of the private health
practice and misuse of public health functionaries is distinct. In 199?-94 the expenditure
on private health care was 1.5 times more the total public health expenditure. In 2002-0?
the private health expenditure was nearly 5.4 times the public health expenditure. The
crushing burden of paying for their health care is put on the people of this country,
including the poorest, resulting in out-of-pocket expenditure on private health care
services, which is as high as 82 per cent in the country. NHP 2002 in principle,
'welcomes the participation of the private sector in all areas of health activities —
primary, secondary or tertiary. This is in contrast to the basic goal of NHP-1983 of
providing 'universal, comprehensive primary health care services, relevant to actual
needs and priorities of the community".
India has a very large and unregulated private health sector
In 2001 of all registered hospitals 73% were in the private sector and 27% in the public
sector. While public hospitals follow some norms and standards in provision of health
care, as defined in hospital manuals and government regulations, the private sector is
bound by no such norms and operates completely unregulated. The professional
associations show scant concern for ethics and sell-regulation to cnsuie adequate
standards of health care provision. The private sector is governed completely by the
whims of the market, and has a focus on curative care. Various studies show that private
health sector accounts for over 70% of all primary care sought, and over 50%o of all
hospital care. This is not an acceptable scenario in a country in which three-fourth of the
population lives at or below subsistence levels.
A lopsided health policy resulting in urban-rural disparities
‘I
The population distribution in the country is 70% rural; the distribution of health services,
however, does not reflect this. There are 17,000 hospitals (34 per cent rural), 25,670
dispensaries (40 per cent rural) and about one million beds (23 per cent rural) at present
in the country. In addition the rural areas have 24,000 PHCs and 140,000 sub-centres.
However, the comparison between urban and rural areas shows that■ ■
Indicators
__________________
Hospitals____________________ __
Dispensaries
_______________
Hospital beds per 100,000 population
Urban (in %)
4,48________
6.16________
308
Rural (in %)
0.77_______
1.37
44
I
Unequal access to health care and poor outcomes based on socio-economic status
Those in the lowest socio-economic strata in India are severely deprived of health care
facilities, leading to poor health outcomes, as accessibility to basic health care depends
on the socio-economic status of an individual. For resource poor households access and
outcomes as compared to the socio-economically well off class are significantly more
adverse for the former.
2
an©
Women are at a higher risk of having untreated ailments in rural areas (18.3%) than in
urban areas (8.8%); for men it is (15.8%) in rural areas and (8.1%) in urban areas. Non
availability of essential determinants of health like water supply and sanitation, lack of
hygiene and access to food contributes further to poor health outcomes. According to the
National Family Health Survey of India 1998 Piped water is available to only 25% of the
rural population and 75% of urban population. 50% of the urban population and 75% of
the rural population does not purify/filter the water. Flush and pit toilets are available to
only 19% of the rural population as against 81% of those in towns and cities. Electricity
for domestic use is accessible to 48% rural and 91% urban dwellers. For cooking fuel
73% of people in the villages still use wood. 48% urban households but only 6% rural
households access LPG and biogas. 41% village houses are semi permanent whereas only
9% of urban houses are so.
2.0
Need and Rationale
Health as a Human Right
The increased Structural Adjustment Programs (SAPs) have had a serious toll on the
health of the people with lite Public Health System in the country being constantly
undermined in favour of Private Sector. The Indian health scenario is characterized by a
declining public health system, resulting in urban-rural disparities and putting the onus of
health care on out-of-pocket expenditure, which is overburdening the impoverished
masses of the country. The unrestrained growth of the private health sector has resulted in
denial of health care to the people of this country thus making a mockery of the concept
of Welfare State enshrined in the Constitution of India in Article 38. Health forms an
integral pejrt of Life with Dignity as enshrined in Article 21 of the Indian Constitution.
The State is increasingly abdicating its primary duty of the Welfare State and has failed
to provide basic primary health care services, which are easily available, accessible and
affordable to all. This' has resulted in increasing denial of health care to the People
especially the marginalised. It is time to work towards establishing Health as a Human
Right in the country to make Health For All a reality in terms of accessibility to and
affordability of Basic Health Care to people. The recommendations of National Health
Policies have not been implemented in letter or spirit.
i
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For complete article on this go to http: / /www.cehat.org/rthc/policybrief2_.pdf
1. Under the above scenario we have a situation in India wherein we are increasingly
moving towards the “Buying” of health care and as a result of which Health as a
Human Right is given the go-by.
2. Increased privatisation has pushed families Below the Poverty Line (BPL) and as
a result medical care is the second most cause for rural indebtedness. On an
average a rural family spends 50% of its lifetime income on medical care alone.
3. Human Rights have no place in Private sector. Only profits and money do the
talking.
4. Under the garb of Public Private Partnerships (PPP) the Karnataka Government is
busy handing over the PHCs to the private parties. One thing that needs to be
3
borne in mind, by privatisation even though we might think that service delivery
might improve, it would only be in the area of some medical care delivery and not
in the prevention and promotion of health which are the essential components of
Primary Health Care
Efforts towards addressing the Right to Health Care by the People’s
Health Movement in India
3.0
>
The First National People’s Health Assembly (PHA-I) was held in Kolkata in
December 2000 when people from all over the country representing 22 major
networks working in varied sectors like Science Popularisation, Labour Issues,
Livelihood, Health Resource generation etc., came together in solidarity to
analyse, debate and act on why “Health for All by 2000 A.D” didn’t happen. The
Assembly resulted in the formation of People’s Health Movement, India (Jan
Swasthya Abhiyan, JSA)
> During the Assembly a People’s Health Charter was brought out which is the
largest consensus document on Health and translated to various languages. This
charter brought out the concerns of the Civil Society regarding Health scenario in
this country and also action points for making “Health for All” a reality
>
JSA alongwith all its state chapters conducted joint public hearings with the
National Human rights Commission in 2004 on the denial to health care. NHR.C
gave strong recommendations to the state to make health care accessible to all. A
number of flaws in the health system such as pending vacancies, availability of
drugs etc. were asked to be corrected. Karnataka too was part of the southern
regional public hearing held in Chennai.
>
In march 2004, just before the National General I*lections .ISA held a dialogue
with the mainstream political parties on the Issue of Health and as a result of
which the Common Minimum Program for the first time talked about health
issues and the budget increase
> JSA’s involvement in the National Rural Health Mission (NRHM) and subsequent
development of standards as guidelines for primary health centres was also an
important step. The states have been actively involved in planning and monitoring
of this Mission by means of Rural Health Watch
4.0
I
Janaarogya Andolana Karnataka (JAAK):
i
Janaarogya Andolana, Karnataka (JAAK) or People’s Health Movement in
Karnataka works under the broad framework of Right to Healthcare. Some of the
efforts that have been undertaken to address the Right to Health issues in
Karnataka
i
I
4
It has brought together a number of state level networks / organisations around the
issue of Health Rights
Karnataka was also very actively involved in the First People Health Assembly.
Health Messages were taken to the people by street theatre and culminated in the
first State Health Assembly at Davanagere in 2000
>
I
In Karnataka a health task force was constituted in 2000 to look into the public
health system. A number of eminent health activist experts who were part of
People’s Health Movement were part of this task force and their
recommendations were enshrined in the Karnataka Health Policy document which
was passed by the state cabinet.
Karnataka was also part of the NHRC Public Hearing on the denials of Health
.Care in 2003. The documentation of cases of denial of health care by members of
JAAK
I
Public hearings were held where the cases were presented before Government
officials and NHRC members. The NHRC gave some specific recommendationsto the Central Government, State Government and civil society based on the
public hearings and subsequent discussions
>
I
In 2005, the second State health Assembly was held in Karnataka before the 2nd
International People’s Health Assembly at Cuenca in Ecuador, South America.
Janaarogya Andolana, Karnataka has made several efforts in the past years to
mobilise people around the health issues.
Since 2006, a statewide campaign has been launched towards revitalisation of the
Primary Health Care in Karnataka
5.0
Right to Healthcare Campaign in Karnataka
As a part of the strategy to achieve right to healthcare, it was felt that the
functioning of healthcare institutions especially the Primary health Centres,
needed to be addressed urgently, as they played a key role in the delivery of
health care.
''Primary Health Centres are the cornerstone of rural health services- a first port
of call to a qualified doctor of the public sector in rural areas for the sick and
those who directly report or referred from Sub-centres for curative, preventive
and promotive health care. "(IPHS 2006)1
Karnataka is one of those states where privatisation of medical education,
privatisation of health care has taken place in an intense manner. Despite many
5
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recommendations and a health policy in place, the Primary Health Care that
should be available to people at the village is not being available to them due to
several reasons.
The meeting of JAA-K to commemorate World Health Day in April 2006 was a
turning point for this campaign. The people from various districts who had
collected information on the state of Primary Health Centres (PHCs) and
presented it before the Government officials, were very disappointed with the
Government’s response. They decided to take up the issue and follow it up with
renewed vigour. That led to the formation of an issue based group within JAA-K
who took up the issue of Revitalising Primary Health Centres as their primary
focus. This group has been meeting regularly to discuss the issues further, to
collect information related to PHCs from various sources, to create awareness on
the issues related to primary health care, to bring in Non-Governmental
Organisations (NGOs) and Community Based Organisations (CBOs) from various
districts of Karnataka to join the campaign, to prioritise issues, and to plan a
strategy to revitalise primary health centres
Towards this, state-wide consultations were held involving number ol people
from various districts, different networks, federations of community based
organisations and human rights groups. The common issues that have emerged
are,
> Health care to people is not available to people in the Primary Health Centres in
many of the districts due to the staff including medical doctors/nurses not being
appointed, appointed staff sent to deputations to other jobs, the remaining being
involved in their private practice and being highly irregular to PHCs.
> Supply of essential drugs is inadequate. The prescribed budget is Rs.75,000/- lor a
populations of 30,000 ( a paltry Rs.2.50 per head per annum)
I
> In many PHCs equipments are in very rusty conditions and many of the PHC s the
sputum testing instruments like microscopes are not available for a basic disease
like TB.
> Another major finding was that Infrastructure of PHCs was not adequate to
address the health needs of the people - not having electricity connection,
buildings not being repaired for number of years, the PHC staff not having
residence with living conditions, not having water supply, lack of labour rooms,
pharmacy etc are the major findings.
> Rampant corruption in PHCs by way of taking money for services, drugs being
sold to the nearby medical stores where people are made to purchase from, etc.
> The rude behaviour and unfriendly attitude of the staff was of great concern.
6
I
For the first phase of the campaign, it was decided that the Primary health Centres
would be the main focus, as it was supposed to meet much of the healthcare needs of
the population. JAA-K members have been meeting regularly to identify issues and to
prioritise them for the campaign. Of the many issues discussed, it was decided to
focus on 4 broad areas initially -
i)
ii)
iii)
iv)
Staff
Medicines
Equipments
Infrastructure
This campaign builds on the efforts that have already taken place in Karnataka and in the
country on implementing certain standards in the functioning of primary health centres.
Though the earlier efforts built up a consciousness on the standards, and did make some
changes in the system, there is much more to be achieved. Some of the documents which
are being specifically used in shaping the strategy of this campaign include the Indian
Public Health Standards for Primary Health Centres (Government of India, March 2006)
developed through the National Rural Health Mission; Karnataka Health Policy 2004;
National Human Rights Commission (NHRC) Recommendations on Right to Health Care
- 2004; Recommendations of the Karnataka Task Force on Health 2001 and some
Supreme Court & High Court rulings related to health.
I
The Actions that have happened so far in Karnataka
1. Since April 2006, serious efforts have been made to take the health issues to the
other partner organisations / networks so that health is put on the agenda of action
in these organisations / networks
r
2. District Level forums to work on health have been emerging
i
3. Mobilisation of the people on health issues have happened at the community level
resulting in some action at the local level by the people
4. The Study of the Primary Health Centers and their consolidation have been
undertaken in 13 districts and many more districts are undertaking them now.
5. On February 1, 2007 a simultaneous mass action happened in 13 district
headquarters demanding Right to Health Care. The problems associated with the
Health System were presented to the concerned district authorities
6. Districts where the campaign took roots were: Chamarajanagar. Mysore,
Shimoga, Kolar. Bangalore rural. Bangalore Urban, Tumkur. Chitradurga,
Dharwad, Gadag, Belgaum, Raichur and Koppal.
7. Media Advocacy was undertaken by the districts to highlight the state of health
system
7
Success Stories
As a result of all these efforts there have been very marginal improvements and responses
from the Health Administration. Some places corruption has marginally come down,
while in some other place the PHC / Sub center buildings are coming up. Elsewhere
appointments of the staff has happened etc., At the state level the state has acknowledged
the detrimental effect of arrack on health and has banned the same. O.P.Ds in Public
Hospitals have been asked to open in the evenings between 5.30 pm and 8.30pm. Some
of the PHCs are sought to be converted into 24 / 7 to cater to emergencies. Major
Systemic changes are yet to happen and hence the necessity for a political advocacy
6.0
Objectives of the current Campaign
> Working towards making Health as a Human Right and to put health on the
agenda of various people’s movements, organisations, networks and CBOs;
> To revitalize the functioning of the Primary Health Centres with adequate stall,
adequate supply of essential medicines, adequate and basic .infrastructure;
> To make PHCs more accountable to the communities;
‘f
> To increase people’s accessibility to Primary Health Centres and right to primary
health care;
> To evolve a cadre based network of people to work towards the process of health
i • i .
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as human right;
I
> To do strong advocacy with the political system for making health a major
Political agenda
7.0
l
Interventions Planned
Strategies:
1. Organic evolution of district level health action fora;
2. Community Based advocacy towards making the health system respond to people
by using Research, Right to Information Act, public hearings, media, mass actions
3. Utilisation of all the various forums of the partner organisations / networks to
promote health advocacy and action. Mobilisation of communities . CBOs.
networks and Movements.
4. Building state level and district level cadre for the long term health movement by
capacity building, awareness, trainings;
8
5. Continuous perspective building of the people’s movements, organisations,
networks and CBOs;
6. State level Policy and Political advocacy linked to the local action and advocacy
8.0
Action Plans
The Action Plan envisaged is for a minimum of 3 years to
Formation of District Health Action Forum:
.
.
.
District meetings, sensitization, perspective building
Consolidation with trainings
Evolving the functional systems in the forum
Community Based Advocacy:
Survey and documentation of status of Health Systems
Documentation of cases of denial of health care
Using tools of like PHC survey and findings, lobbying with the district health
officer, Zilla panchayats, Right to Information Act, public hearings etc.,
Dialogue with the Health Systems
Mass actions by people at the local level
Formation of People’s Health Watch committees at the panchayat and PHC
level
Community participation, ownership and monitoring of the Health Systems
.
.
.
.
.
•
.
i
Local Actions: At the village, Sub-center, PHC and Taluka level people will take action
to dialogue with the local health officials. They will also use Signature Campaigns, letter
camapaigns to pressurise the Health System to respond for better health care.
State-wide coordinated action: Every district simultaneously will hold various
programmes to address issues of public health and primary health centres. A series of
small scale mass actions are planned to keep sustained pressure on the state to heed to
people's grievances
Public Hearings on the Denials of Health Care and by Health Systems
o Advocacy with the elected representatives in Panchayat, MLAs, ZP
Members, TP members, MPs etc.,
o Public Rally in the District etc.,
o Press Conference and Media dissemination
o
!
I.
9
^17
On October 08, 2007 on the same day a simultaneous state-wide action in all the District
Headquarters has been planned to demand Health Rights. It would be in the form of a
public event either a rally, protest, memorandum submission, dialogue with the district
health authorities, presentation of the denial of health cases in front ol the district
authorities, public hearing etc..
State level Public actions: The state working group consisting of delegates from each
district and state level core group will plan state level action which represents all districts
to take up issue with the state health ministry, directorate of health services, legislative
assembly using media campaign, protest meetings etc.
1. Planning process was initiated towards this end during the state level
meeting on July 15th 2007, it was decided that a state-wide and state level
political Advocacy convention or Rally to be planned. Also to build up the
campaign at the local level, each District was to make its own specific plans
I
2. District Level Action Plan preparation by all the partner organisations in that
District before 20.08.2007. For this District level meetings where the
organisations come together and decide the action plan has been planned.
3. The subsequent state level meeting on 20.08.2007 where all the districts brought
their action plan on board (Please find the list of Action Plan prepared by the
various districts in Kannada enclosed)
4. Training sessions will be planned for the various districts depending on their
action plans.
*1
5. In December 2007 - January 2008, a state level political action has been planned
in Bangalore. This is envisaged more as a political advocacy event with the
dialogue to be held with the various political parties to pressurise the slate to
increase health budget etc.,
! i
This marks the first stage of the 3 years plan. Ongoing plans include
Cadre building:
Cadre building for the state by identifying
• At the district level 2 to 3 persons who would have the potential of being
health activists
• 1 to 2 persons from amongst the NCOS, networks
• Capacity building of the cadre on broader determinants of health through
regular residential workshops
10
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I
.
.
Identification of the potential people in the various districts who have the
time and the interest to take up health related issues at the district level on
a consistent basis in the coming years
Training and capacity building of these people on all health related issues
and grooming them into being health activists
These Actvists would then be the fulcrum around whom the Districts
would rally around for relaisation of their Health Rights
I
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JANAAROGYA ANDOLANA KARNATAKA - (JAAK)
D
tjdjaert
<£oeo rfcoo&z?
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REPORT ON STATE WIDE PUBLIC ACTION DEMANDING RIGHT TO
HEALTH ON OCT 29, 2007
A placard read “100 crore rupees for one MLA, but only Rs.2.50 for ensuring health care ner
Kannadiga per year I The placard said it all- the apathy and neglect of the publiAealth system hv
h« success, v« G„ve,™en,s of the s«e of
and ,he fimmX C
agams a very coirupt and self-centered political system. More than 6000 people carrying su^h
p acards, in across 17 districts, came out on streets demanding Health as their fundamental riaht in
(JAAkT'w "Pe0Pd S He?h rACti°n Da-V” Organized by Jana Arogya Andolana - Karnika
People's S,» faSe"
’g
U''8'n, "d C0',Ce,ted
fr°"'
“ “'“"S
he People s Health Action Day' was a call given by JAAK to the people of Karnataka to
piotest against the government apathy and neglect of the Public Health System which has resulted
maige.scale denial of the right to healthcare of the citizens especially the poor and rural people
and to demand for revitalization of primary health centers. JAAK coordinated the Karnatakf State
eople s Health Action Day” on October 29. 2007 across 17 districts in Karnataka
First and foremost, we would like to celebrate the great success of “People's Health Action Day”
held on 29lh October
across 17 districts of Karnataka. The encouraging news of a large and
enthusiastic participation’ <“u pfe°PT
‘ lTOm
'
across Karnataka stands testimony for our concerted
actions and growing strength of JAAK. Let us all take
e a moment to celebrate the growing strength
of JAAK and we hope this moment will serve as
the stimulus for further action and struggle
towards our goal of “Health for All - NOW'1!
I he news from various districts is slowly pouring in into the secretariat and \
we have contacted
n Shi'inTh™1!-' tThe initial eStimateS Of people’s ParticiPation across the’sute'standsTt
mote than 3000. The distiict wise participation of people stands as below:
Karnataka State People’s Health Action day on 29.10.2007.
SI.
Name of the districts
no>
No of people participated
Chama rajanagar
—————
(Including a rally in Kollegal taluk head quarters
with more than 200 women participants)
Chitradurga________
Shivamoga
4 Dhavanagere______
Bhagalkote
_______
Dharwad______
7 Gadag
2
2
2
2
2
Z2o
500
500
100
120
350
400
400
I
_________ 100
8 Raichur__________
9 Chikkaballpur
10 Bangalore urban
11 Bangalore rural/city
300 ~~
’___________
50
250
___ 85____
40
12 Kolar____________
13 Belgam__________
14 Mandya_________
15 Haveri
_______ _
16Tumkur_________
17|Mysore__________
______ Press meet
Planning for 2nd November
_____ Not happened
Not happened
Coordinated by respective district level forums, people held rallies in district headquarters raising
awareness on Government inaction in its obligation to provide health care to the people
registering protest against such inaction and submitted memorandums to the Government servants
including the District Health Officer. Chief Executive Officer of Z.P. and the Deputy
Commissioner demanding accountability. The memorandums highlighted the sorry plight of the
public health system in the respective districts and listed out local issues of uigent concern and
requiring immediate corrective measures to revitalize an almost dead public health system. Some
of the cross cutting issues of grave concern emerging from the collective action day were rampan
corruption in the public health system, non-availabihty ol doctors and nurses during c
hours, non-availability of medicines and diagnostic facilmes, shortage °f doctors an^
. ,h
rural areas, privatization of and introduction of user fees in medical education and public healt
system. And adding to the feathers of privatization, commerciahzation and corrupfori n
healthcare sector, the feather of apathy is evident from the tact that in the year 2006-07 the stat
has returned Rs.120 crores of the 160 crores allocated to National Rural Health M ssmn
(NRHM), illustrating the highly ineffective and almost defunct situation of the public hea th
system in the state. In lieu with the gross deficiencies identified the protestors were demanding 01
recruitment of and equitable distribution of health staff in rural areas, increased budgetary
allocations for buying drugs and providing diagnostic facilities, strengthening health system at
various levels, operationalizing round the clock service providing health centers, regulation of
private health care sector, stopping the privatization of government health services ending the
corruption in public health system, improving the basic infrastructure ol health facilities,
providing adequate housing and facilities to government health staff, making pubhc■
ini’rL'
accessible and responsive to the needs of people living with disability and HIV-AIDS and
.
effective implementation of NRHM.
We, the JAAK secretariat, would like to congratulate all the JAAK district forums for the
enormous time and efforts they have put in mobilizing people and making “People s Health
Action Day” a meaningful and successful one.
' (with
' ' h two representatives from each
JAAK is now planning to hold a 2-day State Level meeting
and 13th of November at Bangalore with the following igenda:
district JAAK forum) on 12th L-.
.
.
Share and reflect on the “People’s Health Action Day” experiences from different d^tricts
Director of State Health and Family Welfare
Collate a compilation report and meet the
1
department to have a formal dialogue oni the status of public health in the state
Plan and strategize for the follow-up action on the state wide “People’s Action: Day” and
give renewed momentum for the JAAK
2
wr
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Dr. Prakash Rao, Premdas, Prabha, Basavaraju, Prasanna, Obalesh
I he Stale Steering Committee,
Jana ArogyajAndolana - Karnataka
Bangalore
29th Oct 2007.
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One of the indirect results (cant ascribe as a Direct fallout) of this sustained campaign
has been the ban on arrack sales in Karnataka (which was promised to us by the Health
Minister• during a Dialogue one of the Partner networks GMO had, at their annual
meeting, with inputs from JAAK). Also in the recent budget announcement the evening
OPD hours have been extended in the Government Hospitals with the Medical Officers
paid at Rs. 300 per hour extra. Unfortunately this has been done to the Hospitals and not
the PHCs.
All those who were involved in the campaign from the various districts also attended the
State Level Health Assembly on March 21sl preceding the Second National Health
Assembly (NHA-2) held in Bhopal from March 23rd to March 25th. About 100 people
participated in NHA-2 from Karnataka
What could have been better?
I
1. We have to still reach a critical mass of Districts as 13 is still not enough show of
Strength. We are working towards the same.
Capacity
building of the District level people hasn’t happened enough. People are
2.
still looking towards the small core of people to deliver. As a result of this some
of the Districts aren’t having people who can take this forward by themselves.
3. Organisations are appreciating that working on Health is important and are
coming for the campaigns/events but the process oriented approach is still missing
with Organisations allotting specific people within themselves to work on and
towards health ( also partly due to conflicting priorities)
What Next?
1. We are in the process of collating and consolidating all the data from the Districts.
This would be the next step
2. Wcj arc planning a State level convention in which a dialogue with the System (
political parties, Government, Department) is envisaged
3. Regional Level Workshops for capacity building of the District level workers
4. Dialogue and connection with the other Movements like Right to Food, Campaign
Against Water Privatisation, Women’s groups, Anti-arrack groups etc., is to be
strengthened
A Rally in Tumkur District under JAAK Banner
I
SHG women members handing over the Memorandum to the DUO in Gadag District
Mysore District people handing over the memorandum to the DC of the District
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NOVARTIS BOYCOTT CAMPAIGN
About the Campaign
Novartis, the Swiss Multinational pharmaceutical company, has filed a case in the Chennai High Court
against the order of the Chennai Patent office rejecting the patent application filed by them for getting
a patent on imatinib mesylate, the trade name being ‘Gleevec’. Imatinib mesylate is extremely useful
in the treatment of chronic myeloid leukemia (CML). Currently it is being produced in its generic form
by NATCO, Cipla. Ranbaxy and Hetero as well as by Novartis under the brand name Gleevec.
Treatment with Gleevec, the Novartis’ brand costs Rs. 1.2 lakh (2500 US dollars) per month, whereas
the Indian generic versions cost about Rs. 8000 (175 US dollars)! If product patent is granted to
Novartis for imatinib mesylate, the Indian generic versions will be forced to go out of the market,
while the treatment of the CML would cpst Rs. 1.2 lakh per month and this would go out of the reach
of 99% of the patients of CML. Novartis’ price is a clear example of excessive pricing which it has
enforced across the world. There is no explanation as to why Novartis is not offering different prices
depending on the circumstances in a country like India. It is clear that they are only interested in
placing profits before patients’ lives.
The Novartis’ claim for patent on the beta crystalline form of imatinib mesylate is objectionable. This
is because though this beta crystalline form is less hygroscopic is easier to process, stores better, it
doesn’t satisfy the two essential criteria of patentability - innovative step and non-obviousness to those
familiar with the art. Imatinib mesylate is not a new molecule. Converting the already existing drug in
to crystalline form is not an innovative step or is not non-obvious. To claim a patent on the crystalline
salt form of imatinib mesylate is entirely unacceptable.
Novartis claims that those patients, who cannot afford to purchase Gleevec, receive the drug free of
charge, through Novartis’s Glivec International Patient Assistance Programme (GIPAP). Novartis says
that 6,700 patients get free Gleevec, whereas in India 20,000 patients suffer from chronic myeloid
leukemia every year. Dr. Purvish Parikh, professor and chief of medical oncology, Tata Memorial
Hospital, has filed an affidavit based on his experience, debunking the claim of the Company about
GIPAP.
I
Novartis claims that Chennai Patent Office’s rejection of Novartis patent for Gleevec violates TRIPS.
If so then this claim should be taken to the special international dispute redressal mechanism under
WTO, which deals with such matters. However, instead, Novartis has decided to approach Chennai
High Court in India. It has dragged the Indian Government and cancer patients to court and challenged
the constitutional validity of an extremely important public health safeguard in India’s patent law. This
is highly questionable. Put all these facts together we sincerely feel that the act of the company to get
patent for Gleevec is motivated by desire to get huge profits at the cost of the patients suffering from
Chronic Myeloid Leukemia. If Novartis wins this case, other MNCs would also claim patents for
similar, already well-known medicines and there will be the danger of making a series of medicines
out of the reach of ordinary Indians. Since India also supplies cheaper, generic drugs to the tune of
thousands of crores to many developing countries, this will also be adversely affected. Patents in India
threaten a key source of affordable medicines. India produces affordable medicines that are vital to
many people living in developing countries. For example, over half the medicines currently used for
AIDS treatment in developing countries come from India.
1
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—•'ofXX“A™dlDb0C‘”S ™“,1B“d'rs ^^P’^^^w doc.orswithoutborders^rg/)-
o^Z^XdS
fe=S^=s==
Ey “ t" „ ■? te™ ,ik
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up “Boycott Novartis Products Campaign” as th^C3116018 hAF"K f6eIS strongly that y°u should take
appeals from various people all oveMhf worlrH C
has not resP°nded positively to earlier
about the imatinib mesylate patent In flc7f)AF
i!\Wh°lly unJustified and anti-people stand
who would indulge in similar acts.
d H k Slgna S t0 °ther Pharmaceutical companies
downloadeSS&^o^S8he c~
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National Rural Health Mission
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National Rural Health Mission
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A summary of
Community Entitlements
and
Mechanisms for Community Participation and Ownership
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Community Leaders
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Prepared for
Community Monitoring of NRHM - First Phase
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A Promise of Better Healthcare Services For The Poor
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Briefing Note Compiled by: Abhijit Das, Gitanjali Priti Bhatia
Illustrations by: Ganesh
Printed at: Impulsive Creations - 9810069086
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A Promise of Better Healthcare Services For The Poor
Contents
Preface
04
An Introduction- NRHM
05
Service Guarantees Important Schemes and
Provisions under NRHM
06
i
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ES
ASHA
ANM
■
Bfl
JSY
Service guarantees from Sub Health Center
E
Service' guarantees from Primary Health (’enter
Service guarantees from Community Health Center
AYUSH
I.
1
Community Participation in NRHM
R
EE
KI
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Some Frameworks for Community Monitoring
n
Indian Public Health Standards
Charter of Citizen’s Health right
B
Concrete Service Guarantees
EJ
Annexure
■
14
Village Health and Sanitation Committee
PHC Monitoring and Planning Committee
Block Monitoring and Planning Committee
District Health Monitoring and Planning Committee
State Health Monitoring and Planning Committee
Rogi Kalyan Samiti
Model Citizens Charter for CHCs and PIICs
20
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A Promise of Better Healthcare Services For The Poor
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Preface
he National Rural Health Mission has been launched with the
objective of improving the access to quality healthcare services for
the rural poor, especially women and children. The Mission
recognizes that good health is an important component of overall socio
economic development and an improved quality of life.
The most significant aspect of NRJ1M is that it is not a new health
scheme or programme but a new japproach to providing healthcare
services. Some of the important components of this approach is that it
>
>
recognizes the importance of integrating the determinants of health,
like nutrition, water and sanitation with healthcare systems
1
aims at decentralizing planning and management
integrates organizational structures -i.e. the different vertical health
schemes
improves delivery of healthcare services through upgrading and
standardizing health centres
>
introduces standards and guarantees for service quality and
triangulated monitoring systems for assuring quality
‘f
>
provides mechanisms for community participation and management
This short briefing note has been prepared by pooling together all the
manuals and guidelines that have been prepared to guide the
implementation of NRHM and highlights its key component^ which
relate to Entitlements, Mechanisms for Community Participation and
Yardsticks for Community Monitoring. It is expected that this
information will prove useful for all those involved in the Community
Monitoring processes at the district, block and village levels.
This briefing note has been prepared as a part of the Community
Monitoring of NRHM (first phase) being implemented by the Advisory
Group on Community Action.
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A Promise of Better Healthcare Services For The Poor
Some of the Core Strategies through which
the mission seeks to achieve its goals:
An Introduction to
NRHM
f’Tlhe Government of India launched the National
| Rural Health Mission (NRHM) on the 12th of
I
April 2005.The vision of the mission is to
undertake architectural correction of the health system
and to improve access to- rural people, especially poor
women and children to equitable, affordable,
accountable and effective primary health care
throughout the country with special focus on 18 states,
which have weak public health indicators and/or weak
infrastructure.
18 special focus states are Arunachal Pradesh, Assam,
Bihar, Chattisgarh, Himachal Pradesh, Jharkhand,
Jammu and Kashmir, Manipur, Mizoram, Meghalaya,
Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh.
>
Train and enhance capacity of Panchayati Raj
Institutions (PRIs) to own, control and manage
public health services
>
Promote access to improved healthcare at
household level through (ASHA)
>
Health Plan for each village through Village
Health Committee
>
Strengthening existing
CHCs
>
Preparation and Implementation of an inter
sectoral District Health Plan
>
Integrating vertical Health and Family Welfare
programmes at National, State, Block, and District
levels
sub-centre, PHCs and
Unlike previous health programmes, the government
has clearly defined the roles of Non governmental
organization (NGOs) in the Mission. NGO’s are not
only included in institutional arrangement at National,
State and District Levels but also they are supposed to
play an important role in monitoring, evaluation and
social audit.
NRHM is a 7 years programme ending in the year
2012. It has time bound goals and its progress will be
reported publicly by the government.
Some of the goals of the Mission:
Source of Information: Mission document http://
mohfw.nic.in/NRHM/Documents/NRHM%20Mission%
20Document.pdf
Reduction in child and maternal mortality
>
Universal access to public health care services
along with public services for food and nutrition,
sanitation and hygiene
>
Prevention and control of communicable and noncommunicable diseases, including locally endemic
diseases
j
For more Information on NRHM vision, goals,
objectives, strategies and outcomes go to:
1) Framework for Implementation. http://mohfw.
nic.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) Website on NRHM by Ministry of Health and Family
Welfare http ://mohfw.nic. in/NRHM/NRHM. htm
Access to integrated comprehensive primary health care
5
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A Promise of Better Healthcare Services For The Poor
Roles and Responsibilities
ASHA is responsible for creating .^Awareness on Health
including
Service Guarantees and
Important Schemes and
Provisions under NRHM
>
Providing information to the community on
nutrition, hygiene and sanitation
>
Providing information on existing health services
and mobilizing and helping the community in
accessing health related services available at
Health Centers
>•
Registering pregnant women and helping poor
women to get BPL certification
>
Counseling women on birth preparedness, safe
delivery, breast feeding, contraception RTI/STI ancj
care of young child
Since Sub centers were serving much larger population
than they were expected to and ANMs were heavily
overworked, one of the core strategies of NRHM is to
promote access to improved healthcare at household
level through ASHA.
>
Arranging escort/accompany pregnant women and
children requiring treatment/admission to the
nearest health centre.
>
Promoting universal immunization
>
ASHA is a Health Activist in the community
>
>
Every village will have 1 ASHA for every 1000
persons
Providing primary medical care for minor ailments.
Keeping a drug kit containing generic AYUSH and
allopathic formulations for common ailments
>
Promoting construction of household toilets
>
She will be selected in a meeting of the Gram Sabha
>
>
She will be chosen from women (married/widowed/
divorced between 25-45 years) residing in the
village with minimum education up to VHIth class.
Facilitating preparation and implementation of the
Village Health Plan through AWW, ANM,SHG
members under the leadership of village health
committee
>
ASHA is accountable to the Panchayat
>
Organizing Health Day once/twice a month at the
anganwadi with the AWW and ANM
>
ASHA will work from the Anganwadi Centre
>
>
ASHA is honorary volunteer and she is entitled to
receive performance based compensation. Her
services to the community are Free of cost
ASHA is also a Depot holder for essential services
like IFA, OCP, Condoms, ORS DDK etc, issued by
AWW
>
ASHA will receive trainings on care during
pregnancy, delivery, post partum period, New born
care, sanitation and hygiene
Accredited Social Health Activist
(ASHA)
\|j
yith the launch of NRHM, the Government of
India proposed Accredited Social Health
¥
Activist (ASHA) to act as the interface
between the community and the public health system.
Timeline: Fully trained ASHA for every 1000
population/large-isolated habitations in 18 Special
Focus States-30% by year 2007, 60% by 2009 and 100%
by 2010
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Source of Information:
(1) Guidelines on ASHA- It has been envisaged that
states will have flexibility to adapt these guidelines
keeping their local situations in view.
http://mohfw.nic.in/Guidelines%20on%20ASHAAnnex%201.pdf
>
Maintenance of all relevant records concerning
mother, child and eligible couples in the area
>
Providing information on different family planning
and Contraception methods and Provision of
Contraceptives
(2) Framework for Implementation (*) http://mohfw.nic.
in/NRHM/Documents/NRHM%20-%20 Framework
%20for%20Implementation.pdf
>
Counseling and correct information on safe
abortion services
>
Coordinates services with AWWs, ASHA, Village
Health & Sanitation Committee and PRI for
observance of Health Day at AWW center at least
once a month
>
Coordination and supervision of ASHA
>
The Untied grant to the Sub Center is kept in a
joint account, which is operated, by the ANM and
the local Sarpanch
For more Information on ASHA go to:
1) Guidelines on JSY http://mohfw.nic.in/dofw%20website/
JSY_features_FAQ_Nov_2006.htm
2) Website of Ministry of Health and Family Welfare
http://mohfw.nic.in/NRHM
Auxiliary' Nurse Midwife (ANM)
ANM is answerable to Village Health and Sanitation
committee, which will oversee her work.
ANM is a government paid health worker who provides
free maternal and childcare services within a sub
center area. The Mission seeks to provide minimum
two ANMs at each Sub Health Centre to be fully
supported by the Government of India.
Source of Information:
Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/ NRHM%20-%20Framework%20for
%20 Implementation.pdf
Primary tasks of ANM
>
Registration of all pregnancies (ANM along with
ASHA will ensure that all BPL women get benefits
under Janani Suraksha Yojna)
For more Information on JSY go to:
1) Guidelines on JSY http://mohfw.nic.in/dofw%20
website/JSY_features_FAQ_N ov_2006.htm
>
Ensure Minimum 4 antenatal check ups along
with 100 IFA tablets and two T.T. Injections to
pregnant women
2) Website of Ministry of Health and Family Welfare http://mohfw.nic.in/NRHM
>
Appropriate and prompt referral in case of highrisk pregnancies
JANANI SURAKSHA YOJANA
(JSY)
>
Provide Skilled Attendance at home deliveries,
post partum care and contraceptive advice
JSY is meant to reduce maternal mortahty and neo-natal
mortality by promoting deliveries at health institutions
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by skilled personnel like doctors and nurses.
Newborn Carje (full immunization and Vitamin A
doses to children, prevention and control of
childhood diseases like malnutrition, infections etc.
JSY is a 100% centrally sponsored scheme. It
integrates cash assistance to women from poor families
for enabling them to deliver in health institutions along
with anti natal and post natal care.
Curative Services like treatment for minor ailments
7
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A Promise of Better Healthcare Services For The Poor
Assistance for Home Delivery
The scheme applies differently to LPS and HPS.While
states having low institutional delivery rates have been
named as Low Performing States (LPS), the remaining
states have been named as High Performing States
(HPS). LPS states include the states of Uttar Pradesh,
Uttaranchal, Bihar, Jharkhand, Madhya Pradesh,
Chhattisgarh, Assam, Rajasthan, Orissa and HPS states
include Maharashtra and Tamilnadu.
LPS States
HPS States
In LPS and HPS States, BPL pregnant women, aged 19
years and above, preferring to deliver at home is
entitled to cash assistance of Rs. 500/- per delivery.
Such cash assistance would be available only upto 2
live births and the disbursement would be done at the
time of delivery or around 7 days before the delivery by
ANM/ASHA/any other link worker. The rationale is
that beneficiary would be able to use the cash
assistance for her care during delivery or to meet
incidental expenses of delivery.
All pregnant women delivering in
Government health centres like Sub
centre,
PHC/CHC/FRU/general
wards of District and state Hospitals
or accredited private institutions. No
age constraint
Role of ASHA or other link health worker
associated with JSY
Along with fulfilling their usual duties of providing anti
natal and post natal care to woman, ASHA/other health
workers would be responsible for
BPL pregnant women, aged 19
years and above
>
LPS & HPS All SC and ST women delivering in a
government health centre like Sub
centre, PHC/CHC/FRU/general ward
of District and state Hospitals or
accredited private institutions. No
age constraint
Identifying pregnant woman as a beneficiary of the
scheme
Assisting the pregnant woman to obtain necessary
certifications
Identifying a functional Government health centre
or an accredited private health institution for
referral and delivery
'; Limliatiohs of Cash'Assistance for ;
Institutional Dol.y<i^r
OS
>
In LPS States All births, delivered in a health
centre - Government or Accredited
Private health institutions.
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Escorting the beneficiary women to the health center
and stay with her till the woman is discharged
Source of Information: Website of Ministry of Health
and Family Welfare
In HPS States Upto 2 live births.
For more Information on need of BPL certification,
Scale of Cash Assistance for Institutional Delivery
Disbursement of Cash
Assistance, flow of
fund
(from
state
Category Rural Area
district authority to
ASHA’s
Rs.
Mother’s
ASHA’s
Rs.
Mother’s
ANM to
ASHA),
Package
Package
Package
Package
ASHA’s package under
LPS
1400
HPS
700
600
2000
1000
700
600
Generally the ANM/ASHA should carry out the entire
disbursement process.
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200
1200
JSY,. Subsidizing cost
of Cdesarean Section ,
Grievance Redressal
cell, display of names of JSY beneficiaries in health
centers go to: http://mohfw.nic.in/dofw%20website
/JSY_features_FAQ_Nov_2p06.htm
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NRHM
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A Promise of Better Healthcare Services For The Poor
Service Guarantees from Sub
Health Center
>
Correct doses of Vitamin A
>
Prevention and control of childhood diseases like
malnutrition, infections, etc.
(Services provided at the Sub Center are Free
of Cost for a person from BPL family)
Family Planning and contraception
Maternal Health
>
Provision of contraceptives and counseling to adopt
appropriate Family planning methods
>
Counselling and appropriate referral for safe
abortion services (MTP) for those in need
Antenatal care:
> Early registration of all pregnancies
>
Minimum four antenatal check-ups
>
General examination such as weight, BP, anaemia,
abdominal examination, height and breast examination
>
Iron and Folic Acid supplementation
>
T.T.Injection, treatment of anaemia, etc.
>
Minimum
laboratory
investigations
haemoglobin, urine albumen and sugar
like
Identification of -high-risk pregnancies
appropriate and prompt referral
and
>
Adolescent health care
Providing education, counselling and referral services
Assistance to school health services.
Control of local endemic diseases
Disease surveillance
>
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Promotion of sanitation including use of toilets and
appropriate garbage disposal
>
Provide treatment for minor ailments including
and First Aid in accidents and energencies
>
Appropriate and prompt referral
>
Organizing Health Day at Anganwadi centres at
least once in a month
Skilled attendance at home deliveries as and when
called for
Appropriate and prompt referral
Postnatal care:
> A
. minimum of 2^.postpartum home visits
>
Disinfection of water sources
Curative Services
Intranatal care:
> Promotion of institutional deliveries
>
>
Training, Monitoring and Supervision
Initiation of early breast-feeding within half-hour
of birth
>
Training of Traditional Birth Attendants and
ASHA
Counselling on diet and rest, hygiene,
contraception, essential new born care, infant and
young child feeding and STI/RTI and HIV/AIDS
>
Coordinated services with AWWs, ASHA, Village
Health and Sanitation Committee, PRI
I
Record of Vital events
Child Health
>
Promotion of exclusive breast-feeding for 6 months
>
Full Immunization of all infants and children
>
9
Recording and reporting of Vital statistics
including births and deaths, particularly of
mothers and infants
A Promise of Better Healthcare Services For The Poor
>
Maintenance of all the relevant records concerning
mother, child and eligible couples in the area
The Sub Health Centre will be accountable to the Gram
Panchayat and shall have a local Committee for its
management, with adequate representation of Village
Health and Sanitation Committee.
1
I
untied_funds_NRHM.pdf
2) IPHS for Subcenters http://mohfw.nic.in/NRHM/
Documents/IPHS_for_SUBCENTRES.pdf
Services Guarantees from Primary
Health Centre (PHC) I
ANM and Multi purpose Health worker MPW works
from the Subcentre and deliver the above-mentioned
service with the help of ASHA.
(All services provided at PHC are free of cost
for BPL families)
Every PHC has to provide OPD services, Inpatient
Service, referral service and 24 ho'urs emergency
service for all cases needing routine .and emergency
treatment including treatment of local diseases.
Funds
>
>
The Gram Panchayat SHC Committee has the
mandate to undertake construction and
maintenance of SHC. An annual maintenance grant
of Rupees 10,000 will be available to every SHC
All services provided by Sub centers are also
provided by PHC.
Every SHC gets Rs. 10,000 as Untied grants for
local health action. The resources could be used for
any local health activity for which there is a
demand. The fund would be kept in a joint account
to be operated by the ANM and the local Sarpanch
Some additional services provided in a PHC are as
follows:
Maternal Health
>
Time Line:
> 2 ANM Sub Health Centres strengthened/
established to provide service guarantees as per
IPHS, in 1,75000 places - 30% by 2007, 60% by
2009, 100% by 2010
>
>
>
24-hour delivery services both normal and assisted
I
Appropriate and prompt referral for cases needing
specialist care
Untied grants provided to each Sub Centre to promote
local health action. 50% by 2007, 100% by 2008
>
Pre-referral management (Obstetric first-aid)
>
Facilities under Janani Suraksha Yojana
Family Planning
Annual maintenance grant provided to every Sub
Centre - 50% by 2007, 100% by 2008
Procurement and logistics streamlined to ensure
availability of drugs and medicines at Sub Centres50% by 2007,100% by 2008
>
Permanent methods of Family Planning
>
Facility for Medical Termination of Pregnancies
(wherever trained personnel and facility exists)
Treatment of RTI/ STIs
Basic laboratory services
Referral services
Source of Information:
1) Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
Appropriate and prompt referral of cases needing
specialist care including:
For more Information go to:
1) Guidelines for VHSCs, SCs, PHCs AND CHCs
http://mohfw.nic.in/NRHM/Documents/Guidelines_of_
>
10
Stabilisation of patient
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>
Appropriate support for patient during transport
>
Providing transport facilities
Source of Information:
Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
A Charter of Citizen’s Health Rights should be
prominently displayed outside all PHCs.
For more Information go to:
Guidelines for VHSCs, SCs, PHCs AND CHCs
http://mohfw.nic.in/NRHM/Documents/Guidelines_of_
untied_funds_NRHM.pdf
The Primary Health Centre (not at the block level) will
be responsible to the elected representative of the
Gram Panchayat where it is located.
The Block level PHC will have involvement of
Panchayti Raj elected leaders in its management even
though Rogi Kalyan Samiti would also be formed for
day-to-day management of the affairs of the hospital.
The Mission seeks to provide minimum three StaffNurses
to ensure round the clock services in every PHC.
Service Guarantees from
Community Health Centre (CHC)
Care of routine and emergency cases in surgery
and medicine
>
24-hour delivery services including normal and
assisted deliveries
>
Essential and Emergency Obstetric Care including
surgical interventions
>
Full range of family planning services
>
Safe Abortion Services
>
Newborn Care and Routine and Emergency Care of
sick children
>
Diagnostic services through the microscopy centers
>
Blood Storage Facility
>
Essential Laboratory Services
>
Referral Transport Services
>
All National Health Programmes should be delivered
through the CHCs. e.g. HTV/AIDS Control Programme,
National Leprosy Eradication Programme, National
Programme for Control of Blindness
IPuiuLs
>
>
Each PHC is entitled to get an annual maintenance
grant of Rs. 50,000 for construction and
maintenance of physical infrastructure. Provision
for water, toilets, their use and their maintenance,
etc, has to be priorities. PHC level Panchayat
Committee/Rogi Kalyan Samiti will have the
mandate to undertake and supervise improvement
and maintenance of physical infrastructure
Every PHC is entitled' to get Rs. 25,000 as Untied
grants for local health action. The resources could
be used for any local health activity for which there
is a demand'
Time Line:
'■ ’
> 30,000 PHCs strengthened/established with 3 Staff
Nurses to provide service guarantees as per IPHS 30% by 2007, 60% by 2009 and 100% by 2010
1
>
Untied grants provided to each PHC to promote
local health action - 50% by 2007 and 100% by 2008
>
Annual maintenance grant provided to every PHC
Over the Mission period, the Mission aims at
bringing all the CHCs on a par with the IPHS to
provide round the clock hospital-like services.
According to IPHS, it is mandatory to display
Charter of Citizen’s Health Rights outside all CHCs.
The dissemination and display of charter is the
- 50% by 2007 and 100% by 2008
Procurement and logistics streamlined to ensure
availability of drugs and medicines at PHCs - 50%
by 2007 and 100% by 2008
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11
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A Promise of Better Healthcare Services For The Poor
responsibility of Block Health Monitoring and
Planning Committee.
According to IPHS, it is mandatory for every CHC to
have “Rogi Kalyan Samiti” to ensure accountability^
Mission also seeks to provide separate AYUSH set up
in each CHC.
Funds
>
>
Every CHC gets Annual maintenance grant of
Rs. 1 lakh for construction and maintenance of
physical infrastructure. Rogi Kalyan Samiti/Blcck
Panchayat Samiti has a mandate to undertake
construction and maintenance of CHC
AYUSH
The term AYUSH covers Ayurveda, Yoga &
Naturopathy, Unani, Siddha and Homeopathy. These
systems are popular in a large number of States in the
country, e.g. Ayurved system is popular in the States of
Madhya Pradesh, Rajasthan, and Orissa, the Unani
system is particularly popular in Tamil Nadu and
Maharashtra.This is to imply that the AYUSH systems
of medicine and its practices are well accepted by the
community, particularly, in rural areas. The medicines
are easily available and prepared from locally available
resources, economical and comparatively safe.
>
Annual maintenance grant provided to every CHC
-50% by 2007 and 100% by 2008
>
Procurement and logistics streamlined to ensure
availability of drugs and medicines at CHCs-50%
by 2007 and 100% by 2008
I
Modalities For Integration
>
For mainstreaming, the personnel of AYUSH may
work under the same roof of the Health
Infrastructure, i.e., PHC, CHC; However, separate
space should be allocated exclusively for them in
the same building
>
The Doctors under the Systems of AYUSII are required
to practice as per the terms & conditions laid down for
them by the appropriate Regulatoiy Authorities
>
Provision of one Doctor of any of the AYUSH
systems as per the local acceptability assisted by a
Pharmacist in PHC
>
Provision of one Specialist of any of the AYUSH
systems as per the local acceptability assisted by a
Pharmacist in CHC
>
Supply of appropriate medicines pertaining of
AYUSH systems
>
The already existing AYUSH infrastructure should
be mobilized. AYUSH dispensaries that are not
functioning well should be merged with the PHC or
CHC barring which, displacement of AYUSH clinic
is not advised
>
Cross referral between allopathic and AYUSH streams
should be encouraged based on the need for the same
Time Line
> 6500 CHCs strengthened/established with 7
Specialists and 9 Staff Nurses to provide service
guarantees as per IPHS-30% by 2007,50% by 2009
and 100% by 2012
Untied grants provided to each CHC to promote
local health action- 50% by 2007 and 100% by 2008
I
One of the objectives of the mission is to revitalize local
health traditions and mainstream AYUSH into the
public health system.
Every CHC gets Rupees 50,000 as Untied grants for
local health action. The resources could be used for
any local health activity for which there is a demand
>
i
Source of Information:
1) Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) IPHS for CHC(A) http://mohfw.nic.in/NRHM/
Documents/Draft-CHC.pdf
For more Information on Guidelines for Village
Health and Sanitation Committees, Sub Centres. PHCs
and CHCs go to: http://mohfw.nic.in/NRHM/Documents
/Guidelines_of_untied_funds_NRHM.pdf
12
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A Promise of Better Healthcare Services For The Poor
>
AYUSH Doctors shall be involved in IEC, health
promotion and also supervisory activities
>
The IPHS pertaining to AYUSH and also the
detailed manpower and other requirements and
financial projections for the same will be provided
by the Department of AYUSH for further
consideration
Source of Information:
Mainstreaming of AYUSH Systems in the National
Health Care Delivery System- Mohfw.nic.in/ayush%
2015th%20march.pdf
For more Information go to:
Website of Department of AYUSH http://indianmedicine.
nic.in/
I.
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A Promise of Better Healthcare Services For The Poor
constitution and orientation of VHSC. The Untied
grant to be used by this committee for household
surveys, health camps, sanitation drives, revolving
fund etc.
Community Participation in
NRHM
>
Village Health and Sanitation
Committee (VHSC)
Some roles of the VHSC
> Create Public Awareness about the essentials of
health programmes, with focus on People’s
knowledge of entitlements, to enable their
involvement in the monitoring
Tillage level Health and Sanitation Committee
X. / will be responsible for the Village Health
I*’
>
Discuss and develop a Village Health Plan based
on an assessment of the village situation and
priorities identified by the villiagei community
>
Analyse key issues and problems 'related to village
level health and nutrition activities, give feedback
on these to relevant functionaries and officials.
Present an annual health report of the village in
the Gram Sabha
Plans.
This committee would be formed at the level of the
revenue village (more than one such villages may come
under a single Gram Panchayat).
Composition
The Village Health Committee would consist of:
Gram Panchayat members from the village
>
ASHA, Anganwadi Sevika, ANM
>
SHG leader, the PTA/MTA Secretary, village
representative of any Community based organisation
working in the village, user group representative
The chairperson would be the Panchayat member
(preferably woman or SC/ST member) and the convenor
would be ASHA; where ASHA not in position it could be
the Anganwadi Sevika of the village.
>
Participatory Rapid Assessment to ascertain the
major health problems and health related issues in
the village. Mapping will be done through
participatory methods with involvement of all
strata of people. The health mapping exercise shall
provide quantitative and qualitative data to
understand the health profile of the village
>
Maintenance of a village health register and health
information board/calendar: The health register
and board will have information about mandated
services, along with services actually rendered to
all pregnant women, new born and infants, people
suffering from chronic diseases etc. Similarly dates
of visit and activities expected to be performed
during each visits by health functionaries may be
displayed and monitored by means of a Village
health calendar
>
Ensure that the ANM and MPW visit the village on
the fixed days and perform the stipulated activity;
oversee the work of village health and nutrition
functionaries like ANM, MPW and AWW
Training
The members would be given orientation training to
equip them to provide leadership as well as plan and
monitor the health activities at the village level.
Grants available
>
Every village with a population of upto 1500 gets
an annual Untied grant of up to Rs. 10,000, after
14
A revolving fund for providing referral and
transport facilities for emergency deliveries as well
as immediate financial needs for hospitalization
would also be operated by the VHSC
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A Promise of Better Healthcare Services For The Poor
>
Get a bi-monthly health delivery report from
health service providers during their visit to the
village. Discuss the report submitted by ANM and
MPW and take appropriate action
Officer - Primary Health Centre and at least one
ANM working in the PHC area
>
Time Line
Village Health and Sanitation Committee constituted
in over 6 lakh villages and untied grants provided to
them - 30% by 2007, 100% by 2010
Role & Responsibilities
>
Consolidation of the village health plans and
charting out the annual health action plan in order
of priority
>
Presentation of the progress made at the village
level, achievements, actions taken and difficulties
faced followed by discussion on the progress of the
achievements of the PHC, concerns and
difficulties faced and support received to improve
the access to health facilities in the area of that
particular PHC
>
Ensure that the Charter of citizen’s health rights
is disseminated widely and displayed out side the
PHC informing the people about the medicine
facilities available at the PHC, timings of PHC
and the facilities available free of cost. A
suggestion box can be kept for the health care
facility users to express their views about the
facilities. These comments will be read at the
coordination committee meeting to take necessary
action
>
Monitoring of the physical resources like,
infrastructure, equipments, medicines, water
connection etc at the PHC and inform the
concerned government officials to improve it
>
Discuss and develop a PHC Health Plan
based on an assessment of the situation and
priorities identified by representatives of village
health committees and community based
organizations
Untied grants provided to each Village Health and
Sanitation Committee to promote local health action.
50%' by 2007, 100% by 2008
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
For more Information go to:
Guidelines for VIlSCs, SCs, PHCs AND CHCs
■ http://mohfw.nic.in/NRHM/Documents/Guidelines_of_
untied_funds_NRHM.pdf
PHC Monitoring and Planning
Committee
This Committee monitors the functioning of Sub
centres operating under jurisdiction of the PHC and
developes PHC, health plan after consolidating the
village health plans'.
I
3
Composition ,
i
Chairperson:
Panchayat
Samiti
member,
Executive chairperson: Medical officer of the PHC,
Secretary: NGO/CBO representatives
>
30% members from PRI (from the PHC coverage area;
2 or more sarparjchs of which at least one is a woman)
>
20% members non-official representatives from
VHSC, (under the jurisdiction of the PHC, with
annual rotation to enable representation from all
the villages)
>
20% members representatives from NGOs / CBOs and
People’s organizations working on Community health
and health rights in the area covered by the PHC
>
Share the information about any health awareness
programme organized in the PHC’s jurisdiction, its
achievements, follow up actions, difficulties faced etc.
>
30% members representatives of the Health and
Nutrition Care providers, including the Medical
>
Coordinate with local CBOs and NGOs to improve
the health scenario of the PHC area
15
^3
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'-\.-
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A Promise of Better Healthcare Services For The Poor
>
Review the functioning of Sub-centres operating
under jurisdiction of the PHC and taking
appropriate decisions to improve their functioning
>
>
Initiate appropriate action on instances of denial of
right to health care reported or brought to the
notice of the committee
Role & Responsibilities
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
>
Consolidation of the PHC level health plans and
charting out of the annual health action plan for
the block.
>
Review of the progress made at the PHC levels,
difficulties faced, actions taken and achievements
made, followed by discussion on any further steps
required to be taken for further improvement of
health facilities in the block, including the CHC
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
>
Block Monitoring and Planning
Committee
>
This Committee monitors the progress made at the
PHC level health facilities in the block, including CHC
and develops annual action plan for the Block after
consolidating PHS level health plans.
>
>
>
>
I
Analysis of records on neonatal and maternal deaths;
and the status of other indicators, such as coverage
for immunization and other national programmes
I
Monitoring of the physical resources like,
infrastructure, equipments, medicine, water
connection etc at the CHC; similar exercise for the
manpower issues of the health facilities that come
under the jurisdiction of the CHC
Coordinate with local CBOs and NGOs to improve
the health .services in the block
Composition
>
Chairperson:
Block
Panchayat
Samiti
representative, Executive chairperson: Block medical
officer, Secretary: NGO / CBO representatives
30% members representatives of the Block
Panchayat Samiti (Adhyaksha/Adhyakshika or
members with at least one woman)
20% members non-official representatives from the
PHC health committees in the block, with annual
rotation to enable representation from all PHCs
over time
20% members representatives from NGOs/
CBOs and People’s organizations working on
Community health and health rights in the block,
and involved in facilitating monitoring of health
services
>
Review the functioning of Sub-centres and PHCs
operating under jurisdiction of the CHC and taking
appropriate decisions to improve their functioning
>
Initiate appropriate action on instances of denial of
right to health care reported or brought to the notice
of the committee; initiate an enquiry if required and
table report within two months in the committee.
The committee may also recommend corrective
measures to the district level
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
20% members officials such as the BMO, the BDO,
selected MO’s from PHCs of the block
i
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20 Frame work
%20for%20Implementation.pdf
10% members representatives of the CHC level
Rogi Kalyan Samiti
i
16
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A Promise of Better Healthcare Services For The Poor
District Health Monitoring and
Planning Committee
related information and necessary steps required
to correct the discrepancies
This Committee contributes to the development of
District Health plan.
I
Progress report of the PHCs emphasising the
information on referrals utilisation of the services,
quality of care etc.
>
Contribute to development of the District Health
Plan, based on an assessment of the situation and
priorities for the district. This would be based on
inputs from representatives of PHC health
committees, community based organisations and
NGOs
Composition
>
30% members representatives of the Zilla Parishad
(esp. convenor and members of its Health
committee)
>
25% members district health officials, including
the District Health Officer/Chief Medical Officer
and Civil Surgeon or officials of parallel
designation, along ‘with representatives of the
District Health planning team including
management professionals
>
Ensuring proper functioning of the Hospital
Management Committees
>
15% members non-official representatives of block
committees, with annual rotation to enable
successive representation from all blocks
Discussion on circulars, decisions or policy level
changes done at the state level; deciding about
their relevance for the district situation
>
20% members representatives from NGOs/CBOs
and People’s : organizations working on Health
rights and Regularly involved in facilitating
Community based monitoring at other levels
(PHC/block) in the district
Taking cognizance of the reported cases of the
denial of health care and ensuring proper
redressal
Time Line:
Systems of community monitoring put in place- 50% by
2007 and 100% by 2008.
>
>
1
>
>
10% members should be representatives of
Hospital Management Committees in the district
>
Chairperson: Zilla Parishad representative,
preferably convenor or member of the Zilla
Parishad
Health
committee,
Executive
• chairperson: CMO/CMHO/DHO or officer of
equivalent designation, Secretary: NGO/CBO
representatives
I
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Frarnework
%20for%20Implementation.pdf
State Health Monitoring and
Planning Committee
This Committee reviews and contributes to the
development of State Health plan.
Role & Responsibilities
Discussion on the reports of the PHC health
committees
Composition
>
>
Financial reporting and solving blockages in flow of
resources if any
>
Infrastructure, medicine and health personnel
30% of total members should be elected
representatives, belonging to the State legislative
body (MLAs/MLCs) or Convenors of Health
committees of Zilla Parishads of selected districts
(from different regions of the state) by rotation
17
(Far
i
• - -a
v,/
-T.-
>-.■ ■■
'
•' k.-
.
"
■
■
A Promise of Better Healthcare Services For The Poor
>
15% would be non-official members of district
committees, by rotation from various districts
belonging to different regions of the state
>
20% members would be representatives from State
health NGO coalitions working on Health rights,
involved in facilitating Community based
monitoring
would be discussed an appropriate action initiated
by the committee. Any administrative and
financial level queries, which need urgent
attention, will be discussed
>
Institute a health rights redressal mechanism at
all levels of the health system, which will take
action within a time bound manner. Review
summary report of the actions taken in response to
the enquiry reports
>
Operationalising and assessing the progress made
in implementing the recommendations of the
NHRC, to actualize the Right to health care at the
state level
>
The committee will take proactive role to share any
related information received from GOI and will also
will share achievements at different levels. The
copies of relevant documents vkll be shared
25% members would belong to State Health
Department
>
>
Secretary Health and Family Welfare, Commissioner
Health, relevant officials from Directorate of Health
Services (incl. NRHM Mission Director) along with
Technical experts from the State Health System
Resource Centre/Planning cell
10% members would be officials belonging to other
related departments and programmes such as
Women and Child Development, Water and
Sanitation, Rural development
>
The Chairperson would be one of the elected
members (MLAs)
>
The executive chairperson would be the Secretary
Health and Family Welfare
>
The secretary would be one of the NGO coalition
representatives
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
Ftogi Kalyan Samiti (RKS)
Role & Responsibilities
>
The main role of the committee is to discuss the
programmatic and policy issues related to access to
health care and to suggest necessary changes
>
This committee will review and contribute to the
development of the State health plan, including the
plan for implementation of NRHM at the state
level; the committee will suggest and review
priorities and overall programmatic design of the
State health plan
>
For efficient management of Health Institutions
NRHM has proposed Rogi Kalyan Samiti
(RKS)/Patient
Welfare
Committee/Hospital
Management Committee (HMC) . This initiative
is taken to bring in the community ownership in
running of rural hospitals and health centres,
which will in turn make them accountable and
responsible.#
Broad Objectives of RKS#
Key issues arising from various District health
committees, which cannot be resolved at that level
(especially relating to budgetary allocations,
recruitment policy, programmatic design etc.)
18
>
Ensure compliance to minimal standard for facility
and hospital care
>
Ensure accountability of the public health
providers to the community
I
A Promise of Better Healthcare Services For The Poor
Upgrade and modernize the health services
provided by the hospital
>
Grants
To motivate the states to set up RKSs, a support of
Rs.5.0 lakhs per rural hospital, Rs. 1.00 lakh per CHC
and Rs. 1.00 per PHO per annum would be given to
these societies through states. The societies would be
eligible for these grants only where they are authorized
by the States to retain the user charges at the
institution level.*
Supervise the implementation of National Health
Programme
Set up a Grievance Mechanism System
Apart from this, RKS at PHC and CHC will have the
mandate to undertake and supervise improvement and
maintenance of physical infrastructure. RKS would
also develop annual plans to reach the IPHS
standards.*
Time Line*:
> Rogi Kalyan Samitis/Hospital Development
Committees established in all CHCs/Sub
Divisional Hospitals/ District Hospitals - 50% by
2007, 100% by 2009
RKS would be a registered society. It may
consists of following members#
>
>
Group of users i.e. people from community
>
Panchayati Raj representatives
>
NGOs
>
Health professionals
One time support to RKSs at Sub Divisional
District Hospitals - 50% by 2007, 100% by 2008
Source of Information:
1) Framework for implementation (*) http://mohfw.
nic.in/NRHM/Documents/NRHM%20%20Framework%
20for%20Implementation.pdf
2) Guidelines for IPHS for CHC(A)
According to IPJjIS, it is mandatory for every CHC
to have “Rogi Kalyan Samiti” to ensure
accountability.A
3) Guidelines for Rogi Kalyan Samiti (#) http://
mohfw.nic.in/NRHM/RKS.htm
J,
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NRHM
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A Promise of Better Healthcare Services For The Poor
including safe delivery. The RKS would develop
annual plans to reach the IPH standards.*
Time line*
In the first six months since the launch of the mission,
following work should have been completed:
Some Frameworks for
Community Monitoring
Indian Public Health Standards (IPHS)
;; PHS are being prescribed to provide optimal expert
g care to the community and to achieve and maintain
Xan acceptable standard of quality of care. These
standards help in monitoing and improving the
functioning of public health centers.#
IPHS for CHCs provides for “Assured services” that
should be available in a Community health centre
along with minimum requirements for delivering these
services such as:
> Minimum clinical and supporting manpower
requirement
>
Equipments
>
Drugs
>
Physical Infrastructure
>
Charter of Patients’ rights
>
Requirement of quality control
>
Quality assurance in service delivery-standard
treatment protocol#
>
Selection of and 2 CHCs in each State for
upgradation to IPHS
>
Release of funds for upgradation of two CHCs per
district to IPHS
>
2 ANM Sub Health Centres strengthened/
established to provide service guarantees as per
IPHS, in 1,75000 places- 30% by 2007, 60% by 2009
and 100% by 2010
>
30,000 PHCs strengthened/established with
3 Staff Nurses to provide service guarantees as
per IPHS - 30%'by 2007, 60% by 2009 and 100%
by 2010
>
6500 CHCs strengthened/established with 7
Specialists and 9 Staff Nurses to provide service
guarantees as per IPHS - 30% by 2007, 50% by
2009 and 100% by 2012
Source of Information:
i
1) Framework for Implementation (*) http:// mohfw.nic
.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) IPHS for CHC (#) - ht£p://mohfw.nic. in/NRHM/
Documents/Draft_CHC.pdf
For more Information go to:
Link given on Ministry of Health and Family Welfare .
website: http://mohfw.nic.in/NRHM/iphs.htm
Similar standards are being developed for PHCs & Sub
Center.*
Charter of Citizen’s Health Rights
Over the Mission period, the Mission aims at bringing
all the CHCs on a par with the IPHS in a gradual
manner. In the process, all the CHCs would be
operationalized as first Referral Units (FRUs) with all
facilities for emergency obstetric care. *
Charter of Citizen’s Health Rights seeks to provide a
framework which enables citizens to know.
It will be for the States to decide on the configuration of
PHCs to meet IPH Standards and offer 24X7 services
20
>
What services are available?
>
The quality of services they are entitled to.
I
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A Promise of Better Healthcare Services For The Poor
>
I
The means through which complaints regarding
denial or poor qualities of services will be
addressed.#
>
Emergency Obstetric care
>
Basic neonatal care for new born
A Charter of Citizen’s Health Rights should be
prominently displayed outside all District Hospitals,
CHCs and PHCs. While IPHS makes the display
mandatory for every CHC.*
>
Full coverage of services related to childhood
diseases/health conditions
>
Full coverage of services related to maternal
diseases/health conditions
>
Full coverage of services related to low vision and
blindness due to refractive errors and cataract.
>
Full coverage for curative and restorative services
related to leprosy
>
Full coverage of diagnostic and treatment services
for tuberculosis
The dissemination and display of charter is the
responsibility of Health Monitoring and Planning
Committee at that level. E.g. Block Health Monitoring
and Planning Committee has the responsibility to
ensure display of the charter at CHC.*
While the Charter wrould include the services to be
given to the citizens and their rights in that regard,
information regarding grants received, medicines and
vaccines in stock etc. would also be exhibited.
Similarly, the outcomes of various monitoring
mechanisms wo'uld be displayed at the CHCs in a
simple language for effective dissemination.*
Full coverage of preventive, diagnostic and
treatment services for vector borne diseases
Full coverage for minor injuries/illness (all
problems manageable as part of standard
outpatient care upto CHC level)
The charter seeks to increase transparency that would
help the community to better monitor the health
services. *
>
Full coverage of services inpatient treatment of
childhood diseases/health conditions
>
Full coverage of services inpatient treatment of
maternal diseases/health conditions including
safe abortion care (free for 50% user charges from
APL)
>
For more information go to:
Link given on Ministry of Health and Family Welfare
websit?: http://mohfw.nic.in/NRHM/iphs.htm
Full coverage of services for Blindness, life style
diseases, hypertension etc.
>
Full coverage for providing secondary care services
at Sub-district and District Hospital
Concrete Service Guarantees
>
Full coverage for meeting unmet needs and spacing
and permanent family planning services
>
Full coverage of diagnostic and treatment services
for RI/STI and counseling for HIV-AIDS services
for adolescents
>
Health education and preventive health measures
Source of Information:
1) Framework for implementation^1) http://mohfw.nic
.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) IPHS for CHC(#)- http://mohfw.nic.in/NRHM/
Documents /Draft_CHC.pdf
Concrete Service Guarantees that NRHM provide arc
the benchmarks .against which mission functioning can
be monitored and its success can be measured. These
guarantees are As follows:
>
Skilled attendance at all Births
I.
21
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''.A::-
A.
■
A Promise of Better Healthcare Services For The Poor
60% by 2009 and 100% by 2010.
Time Line:
SHCs/PHCs/CHCs/Sub Divisional Hospitals/ District
Hospitals fully equipped to develop intra health sector
convergence, coordination and service guarantees for
family welfare, vector borne disease programmes, TB,
HIV/AIDS, etc.-30% by 2007, 50<% by 2008, 70% by 2009
and 100% by 2012
Source of Information:
Framework for Implementation http://mobfw.nic.in
/N RH M/D oc u me n ts/N RH M c/( 2 0 - (7( 2 0 F r a ine w o r k
20for%20Impleinentat ion.pdf
For more information on:
Institution wise service guarantees go to Annex-Ill of
Framework for Implementation.
Institution-wise assessment of performance against
assured service guarantees carried out-30^ by 2008,
I
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22
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A Promise of Better Health are Services For The Poor
i
Annexure
Model Citizens Charter for CHCs and PHCs
1. Preamble
Community Health Centres and Primary Health Centres exist to provide health care to every
citizen of India within the allocated resources and available facilities. The Charter seeks to provide
a framework which enables citizens to know.
what services are available?
S!
the quality of services they are entitled to.
the means through which complaints regarding denial or poor qualities of services will be
addressed.
K
I
2. Objectives
Kt
to make available medical treatment and the relates! facilities for citizens.
to provide appropriate advice, treatment and support that would help to cure the ailment to
the extent medically possible.
to ensure that treatment is best on well considered judgment, is timely and comprehensive and
with the consent of the citizen being treated.
K
to ensure you just awareness of the nature of the ailment, progress of treatment, duration of
treatment and impact on their health and lives, and
to redress any grievances in this regard.
3. Commitments of the Charter
E
to provide access to available facilities without discrimination.
K
to provide emergency care, if needed on reaching the CHC/PHC.
E
to provide adequate number of notice boards detailing the location of all the facilities.
to provide written information on diagnosis, treatment being administered.
to record complaints and designate appropriate officer, who will respond at an appointed time,
that may be same day in case of inpatients and the next day in case of out patients.
4. Component of service at CHCs
I
b
access to CHCs and professional medical care to all.
M
making provision for emergency care after main treatment hour whenever needed.
23
A Promise of Better Healthcare Services For The Poor
■
informing users about available facilities, costs involved and requirements expected of them
with regard to the treatment in clear and simple terms.
■
informing users of equipment out of order.
■
ensuring that users can seek clarifications and assistance in making use of medical treatment
and CHC facility.
■
informing users about procedures for reporting in-efficiencies in services or nonavailability ol
facilities.
5. Grievance redressal
tn
grievances that citizens have will be recorded.
there will he a designated officer to respond to the request deemed urgent by the person
recording the grievance.
aggrieved user after his/her complaint recorded would he allowed to seek a second opinion
within the CHC.
I
to have a public grievance committee outside the CHC to deal with the grievances (hat ar’e not
resolved within the CHC.
6. Responsibilities of the users
users of CHC would attempt to understand the commitments made in the charter.
user would not insist on service above the standard set in the charter because it could
negatively affect the provision of the minimum acceptable Jevel of service to another user.
■
instruction of the CHC’s personnel would be followed sincerely, and
■
in case of grievances, the redressal mechanism machinery would be!addressed by users
without delay.
7. Performance audit and review of the charter
M
performance audit may be conducted through a peer review every two,or three years after
covering the areas where the standards have been specified.
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Part III:
Taking action: Working with the right to health
Chapter 10
Promoting the right toi health: Activities to promote and
at community, national and
protect the right to health
1
international levels
■ ' h.
I
■
Keys to Chapter 10
jygg •/.*’■$« ■ z-
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key information:
. Political and legol advocacy complement each other and are mutually reinforcing m promoting
and prototingflie right W-healfh; ,
'
'
m
' . It is important to promote cooperation among NGOshnd government in.the deyelopmeht and
implementation of human rights based health policies and programmes; and
; .. ft is equally important that NGOs pursue all available judicial and quasi-judicial ^amsms
and procedures al; sub-national, national and regional levels in order to seek rerntdies tor
violations and hold governments accountable.
, ,1,.,....
key questtons:
..—SI-a—
:•• How might your NGO effectively use t m complementary advocacy activities?
. Given th,
; strategi.A. including human rights groups and NGOs advocating on behalf of the poor,
human rights groups and NGC
vulnerable, or otherwise disadvantaged groups.
hr;
. ,<
,
• : ,
■
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'
key action points:
Activities by which NGOs can promote and protect tire rightto health include:
-
■ ■■
.
. engaging in research and documentation;
; '
- C ,
. increasing public awareness of. the right to health and engaging in commumty education and
’.S'
:
:
„pnv.bu»aes.™5n.w. p...,™*
.
in service delivery; '
.
'
. building coalitions and forming networks;
.an
,
.•
•
.. .
:
.
.oK*
'
:.
t., , ...... y; ; ;
• promoting sexual and reproductive health rights,
.
.
■ . - advocacy efforts relateOHn^^
working with national and regional Cnforecmentq-)rocedures-tomns-r1re-stme--accOuntability.-
Introduction
10.1
strategies that NGOs can successfully use to promote and protect the right to health.
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108
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policies and programmes; those that involve engaging in community education and mobilization; and those
that pursue judicial or other appropriate remedies for violations. They also can address some of the most
typical obstacles to the realization of the right to health including a lack of public awareness about the right
and its associated obligations among policy makers and health
professionals; a lack of political will; and insufficient legal and
‘Human rights advocacy is hardly ever purely legal or
other precedents and mechanisms for enforcing the right and
purely political. The most effective strategies
ensuring accountability.1
combine political action with legal action.
...Ultimately, legal and political actions are mutually
In addition, many health professional associations and healthrelated NGOs are involved, both as policy advisers and service
reinforcing and work together to shape more
providers, in the organization, management and delivery of
equitable policies, standards and attitudes and
health services. For this reason another important element of
assure that governments and citizens comply with
promoting and protecting the right to health is for NGOs to
international human rights law.'
work in cooperation with government authorities to develop and
Women's Human Rights Step by Step2
implement human rights based policies and programmes. (See
section 10.2 and chapter 7.)
But NGOs must be independent of government in order to remain free to challenge any denial by the
responsible authorities of actual or potential violations of the right to health. A key challenge for many NGOs
working to promote and protect the right to health involves balancing these two approaches - independence
from, and collaboration with, governments.3
The bulk of this chapter presents case studies that illustrate NGOs using a human rights approach to health
to good effect. It highlights examples of advocacy projects and campaigns that promote and protect the right
to health through:
• engaging in research and documentation;
• increasing public awareness of the right to health and engaging in community education and
mobilization;
• promoting capacity-building among health professionals and conformity with the right to health
in service delivery;
• building coalitions and forming networks;
• promoting sexual and reproductive health rights;
• advocacy efforts related to international obligations arising from the right to health; and
• working with national and regional enforcement procedures to ensure state accountability
I
i
The case studies present a sample of the strategies and activities available to NGOs in working within a health
and human rights framework. They are intended to highlight how NGOs are promoting and protecting the
right to health in practice and in the context of their own organizational goals and. strengths. Many of the cases
also illustrate the successful integration of overlapping and mutually-reinforcing advocacy strategies. For
example, NGOs that undertake research and documentation of violations can use their results for community
education and mobilization about the situation as well as for seeking a judicial remedy for victirijs by bringing
a case to a domestic or regional court.
The following cases are examples of NGOs using diverse and complementary strategies to advance the right
to health:
■be *;’<5
Cose study 10.1.1
Cyhe Centre jqr Enquiry into Health and Allied Themes (CEHAT) is a research and advocacy group working
;' -?atbotliL, regional and national levels in India. Its objective is to bring about the right to heal th, including
' tlie right to health care, through a health care system that is universally accessible to all, equitable and
; socially just. It aims to achieve this by undertaking research and advocacy to challenge existing hgajtli
care systems. The underlying basis of its work is to develop strategies and to collaborate with other
‘; interested bodies for changes that are based on a human rights approach, as opposed to the traditional
; /. welfare-orientated based approach to health sector reforms.
Its activities fall into the following programme areas: health services and financing; health legislation;
ethics and patients' rights; women and health; and health and human rights. CEHAT has undertaken
research on the above thematic areas and has engaged in wide-ranging advocacy to strengthen and
improve public health services, including experiments in service provision. In addition, it has 109
<jsr
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accumulated extensive documentation on health legislation at the national level and has developed.a i
national and regional health services-and financing database. CEHAT has also investigated and
documented violations of health-related human rights and has attracted public interest by engaging m
litigation in support of the right to health.
For further information, seezmvuicehtit.dr^
I
•
Case study 10.1.2
The Canadian HIV/AIDS Legal Network is an NGpfe^ folded in 1992 and now has more than 250
members in Canada and around the world. The Legal.Nehvork promotes the human nghts of people
living with and vulnerable to HIV/AIDS, in Canada arid internationally through research, legal and
pohcv analysis, education, advocacy and community mobilization. Among other tlrurgs lhe Network
and to human rights abuses. One example of the Network's extensive legal and pohcy assessment work
is its discussion-paper. Human Rights for People Livingnvith HIV/AIDS (2004), available along with
other similar material at the NGO’s website.
/w .
1
10.2
;
■- For further information see wwio.diilslaw.ca
■
The importance of promoting cooperation among NG Os and
government in the development and implementation of
human rights based health policies and programmes
Implementation of the right to health at the national level is the key factor to the enjoyment of the right by
Xe during their everyday lives. In view of this, it is important that NGOs work constructively with
government agencies, policy makers, and public officials in the design, promotion, implementation and
monitoring of policies and programmes (including associated budgets) that conform to the right to health.
Such cooperation between government and civil society can be carried out effectively at mstitu ional
community, and national levels and is a critical element for the implementation of sustainable and relevant
programmes. (See chapter 7.)
Working with the right to health at the national level involves engaging with a range of government
departments including those that are not specifically dedicated to health but whose responsibilities may have
a direct bearing on it. These include, for example, departments responsible for justice, human rights, soc^
affairs, housing and infrastructure, urban affairs, rural development, education, women s affairs, childre .
affairs and indigenous peoples' affairs.
There are a variety of ways in which health professional associations and other NGOs that advocate for healt
can collaborate wkh public authorities to promote the use of human rights standards as cntena for designing
health-rHated policies and programmes. For example, such organizations can contribute .
. designing implementing, managing and monitoring health policies and programmes that focus
on rimedying inequalities and promoting dignity, and that emphasize an integrated and multisectoral approach to health system development;
. identifying barriers to implementing the right to health, particularly those affec mg poor
vulnlrabll or otherwise disadvantaged groups who need special assistance from the stat if
y .
are 4 enjoy the right to health. These groups include rural women, adolescents, people li g
with HIV/ AIDS, children, people living in poverty, indigenous peoples, and persons w
1
. ?dentifying ways to improve the participation of communities in decision-making processes that
affect their health and well-being; and
. building health and human rights standards into the country's programme for development.
110
Health professional associations and other NGOs also have an important role to play in contributing to a
national public health strategy and plan of action that states have a core obligation to adopt and put in place.
(See chapter 4.) CESCR General Comment 14 stresses that authorities should collaborate with civil society,
including health experts, in designing the national strategy and in adopting a framework law that can give effect
to it. Even in times of resource constraint, governments are required to monitor the extent to which the right
to health is realized or not realized, and to devise strategies and programmes for its promotion.
NGOs can contribute to the process of designing and implementing a national public health strategy and plan
of action by, for example:
• helping to establish priorities for the national strategy. This might include contributing baseline
studies, community-based studies or position papers, or by submitting their conclusions to
relevant authorities or for publication in the appropriate professional journals or in the media;
• ensuring that the plan of action takes account of existing gaps in the government's compliance
with its obligations arising from the right to health;
• identifying reasonable steps to close these gaps;
• identifying the resources available to meet government obligations, with a priority on core
obligations, and the most cost-effective way of allocating those resources;
• helping to identify appropriate country-level right to health indicators;
• helping to establish the national targets (benchmarks) to be achieved in relation to each indicator
and the time-frame for their achievement;
• participating in monitoring progress in realizing these targets;
• contributing to the design of appropriate policies by which the targets can be achieved; and
• identifying the most cost-effective way of using the resources available to attain defined
objectives in the strategy and plan of action.
10.3
Engaging in research and documentation
1 he research and documentation of violations of health-related human rights is an essential part of promoting
and protecting the right to health. Reports and results from investigations constitute important advocacy tools
that can be used in other campaigns, both legal and political, including:
• public education and awareness-raising campaigns on the right to health;
• mobilizing public opinion in support of holding government accountable for complying with
their obligations. This might involve promoting civil action related to the documented violations,
including letter writing/email campaigns, petitions, and public demonstrations;
• lobbying public officials who are responsible for the adoption and implementation of legislation
and policies, such as parliamentarians, and national and local government officials, to address
and remedy the documented violations as well as to address broader changes necessary to
improve enjoyment of the right to health. These might include: incorporating international
standaids and obligations of the right to health into domestic legislation and policies; initiating
law reform if existing laws are inadequate; passing relevant new lawk; and improving the
enforcement of laws and policies;
• furthering legal action and seeking remedies for the victims of violations;
.
• seeking quasi-judicial remedies through a domestic administrative human rights body, such as
an ombudsman office; and
• preparing a shadow report to an international or regional treaty monitoring body.
c"w3-‘
•;■■>
.
■
Humau Rights Watch (HRW) established the Children's Rights Division in 1994 to monitor human rights
abuses against children around the world and to campaign to end them. HRW seeks to encourage
governments and civil society to take stronger action to implement the provisions of tlie Convention on
the Rights of the Child (CRC) and to strengthen protections for children. Its HRW Children's Rights
Division sends fact-finding missions to countries where abuses are occurring in which interviews are
carried out with child victims; parents; human rights activists; lawyers; child care workers; and
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government officials. It also works closely with local human rights groups to identify specific abuses
and strategies for change.
After one such fact-finding mission to Zambia, HRW published a report entitled Suffering in Silence.. The
Links between Human Rights Abuses and HIV Transmission to Girls in Zambia (2002). The report documents
the widespread sexual abuse of girls in Zambia and shows how such abuse exposes them to H1V
infection, llie report also analyzes how these abuses violate the rights of children under the CRC. In
April 2003, HRW received a letter from the office of the President of Zambia, Levy Mwanawasa, stating
that, following his review of its report he had ordered the establishment of an inter-ministerial
programme on the sexual abuse of girls in his country.
For further information, see www.hno.org •
Case study 10.3.2
Amnesty International has been documenting and campaigning for disability rights in Bulgaria. The
results of investigative research visits'to mental health institutions by experts representing Amnesty
and the Bulgarian Helsinki Committee togetherSvitft MehtaljDisability Rights International (MDR1)
were published in an Amnesty International refiorf. entitled
Far from the Lyes of Socety.
Systematic Discrimination against People with Mental DisMities (2002). The report focuses on persons
with mental disabilities who are held involuntarilyjn psychiatric institutions or in social care homes for
adults or children. It concludes that they We victfms'of systematic discrimination as a result of their
mental disabilities and that they suffer a broad range of other human rights violations. The report
claims that such violations arise from inadequate legislation and that they are subject to procedures that
fail to conform with international standards,, as Well as from widespread unacceptable practices
including inadequate medical treatment and rehabilitation,■ inappropriate use of restraint and
seclusion, and refusal to take action on complaints of ill-treatment.
The report concludes that these violations should be dealt with through eWorcement of international
human rights standards and by appropriate reforms of the mental health care services. Meanwh le
Amnesty has conducted workshops for staff in two of the institutions that it v.sited and has imitated a
letter-writing campaign, calling for appeals to be sent to the relevant Bulgarian authonties asking them
to take immediate remedial action. Amnesty continues to monitor the situation m social care homes
including actions that have been taken by the Bulgarian authorities to implement the reports
recommendations.
-..yX
• .;•
For further information, see wwio.amnesty.org
Case study 10.3.3
Physicians for Human Rights - Israel (PHR-Israel), as part of a project run jointly with another local NGO,;
maps- hence, a simple task, such as ordering an ambulance into the village, becomes impossible and
the arrival time of an ambulance to a designated meeting point can take up to 45 minutes.
i
In 2000, PHR-Israc! submitted a High Court petition demanding that primary health care clinics be
erected in three unrecognized villages, based on the premise that all citizens of Israel, inespective o
place of domicile, have’the right to primary health care under the National Health Insurance Law
Following this petition, the Health Ministry and the appropriate Health Management Organizations
.were obliged themselves to establish eight primary health care clinics in unrecognized village^.
PHR-Israel and RCUV worked together on this project for over a year The work included field wprk,
ddcumXtion of individual cases, advocacy and dissemination of informat.on^The NGOs issued
"ehensive joint report on health in the 'unrecognized' villages of the Negev, No-Mm s Land (2003).
In addition to its activities in documenting violations and enforcing legal remedies, PHR-Israel has
been rfiZ public awareness of the right to health and has engaged in advocacy to promote policy
changes to end systematic abuses of human rights and of the right to health. It has given priority to
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marginalized groups, including migrant workers, disadvantaged citizens and residents of Israel,
residents of the Occupied Territories, and prisoners and detainees. PHR-Israel also operates an Open
Clinic in Tel Aviv, available to all who do not have health insurance, and it conducts a Mobile Clinic
every Saturday in the West Bank.
For further information, see www.phr.org.il
Case study 10.3.4
Mental Disability Rights International (MORI), a USA-based advocacy organization, conducts research on
and documents the situation of people with mental disabilities around the world. Based on their field
research, MORI also advises governments and NGOs.how to promote and enforce the human rights of
people with mental disabilities in the most efficient way.
In a recent report. Not on the Agenda: Hainan Rights of People with Mental Disabilities in Kosovo (2002),
MDRI documented a large number of violations of the right to health of people suffering from mental
disability. For example MDRI estimated that at least 40,000 Kosovars with severe mental disabilities
have no access to appropriate services; that many existing institutions provide no treatment whatsoever
and have inadequately trained staff; and that physical and sexual abuse in the institutions often goes
unchecked. MDRI found that detention in particular.facilities, the Shtime psychiatric facilities, is itself
a violation of the right to health, because of the failure to treat patients and the absence of protection
for them against physical abuse or sexual violence.
In follow-up to this report, MDRI has opened an office in Kosovo to work on a new project, Initiative for
Inclusion: Kosovo. This initiative aims to provide technical assistance to policy makers and NGOs, to
protect the rights and improve treatment.of people with mental disabilities. Based on their research in
Kosovo, MDRI has defined specific urgent needs as the focus of their initiative in Kosovo:
• Training of staff in mental health institutions to prevent selt-abuse of patients;
• Advocacy for the creation of an oversight system with an independent board to investigate
allegations of human rights abuses,against patients; and
• Advocacy for the closing of one particular institution, the Shtime Institute, and for reintegrating
people with mental disabilities into safe, conununity services and support systems.
Forfurtherihfonnationseewww.indri.org
I
Case study 10.3.5
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Physicians for Fluman Rights (PHR USA) promotes health by protecting human rights. As a founding
.member of the International Campaign to Ban Landmines, PHR (USA) shared the 1997 Nobel Peace
. Prize. PHR (USA) mobilizes the health professions to protect human rights, including the right to
• health, and has built a campaign by health professionals on HIV/AIDS and the right to health. Among
its"varied activities, PHR (USA) conducts research and investigations on the public health effects of
violations of human rights and humanitarian law in internal and international conflicts.
In 2001, PHR (USA) released a report, Endless Brutality: Ongoing Abuses in Chechnya, the result of an
extensive population-based survey of health and human rights abuses of Chechens by Russian forces.
1 The PHR investigation was designed to document human rights violations in the last five months of
; 2000. ,It involved interviewing a random sample of over 1100 people displaced by the war who were
able to provide information on human rights violations. The report's findings include documentation
of torture; the killing of civilians; landmines, booby-traps, and other explosives; and violations of
' medical neutrality. The report outlines the health consequences of such violations of human rights and.
, , humanitarian law and provides detailed recommendations to the Russian Federation; the fighters on
: < the Chechen side; the international community, including the United Nations, the Council of Europe
• and the Organization for Security and Cooperation in Europe; and the United States Government. In
, '' follow-up to the report, PHR (USA) researchers provided expert testimony abuses in Chechnya before
.the US Senate in an effort to promote a commission of inquiry into war crimes committed by Russian
forces and rebel forces, a necessary precursor to establishing an international tribunal to prosecute those
responsible.
For further information see www.phrusa.org
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10.4
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Increasing public awareness of the right to health and
engaging in community education and mobilization
Many countries have legislation that provides for various
elements of the right to health. National laws can offer varying
degrees of protection against human rights violations,
including constitutional provisions on non-discrimination.
Unfortunately, many such laws are not adequately enforced.
Even in countries where key obligations of the right to health
are incorporated into laws and policies, there is often, in
addition to.weak enforcement, very little public awareness of
them. This is often the case especially in rural or geographically
isolated areas. NGOs can help raise public awareness of
international standards, government obligations and national
legislation that protect the right to health. They can also help
raise awareness of the implications of current domestic laws
and policies, particularly for those in need of health care, and
how to benefit from them. Identifying and publicising
violations helps to mobilize public opinion in support of
holding governments accountable for complying with their
obligations.
‘lack of consciousness of health as a right remains a
fundamental challenge — if not the challenge — for
human rights NGOs engaged in promoting the right
to health. ... [I]n order for the right to heath to be
meaningful, it must become part of the
understanding that people at the community level
have of themselves, their well-being, and their
relationship to the state. [Otherwise] violations of the
right to health — whether caused by poverty-related
conditions or by lack of access to health care —
continue to be invisible, [and] accepted as part of the
natural order of things.'
A. Yamin4
For example, a women's advocacy group might invoke the anniversary of its state's ratification of the
Women's Convention to:
• hold a press conference about the health-related obligations its government has agreed to,
comparing these to current national laws and policies;
• highlight illustrative examples of problems that still exist, emphasising the consequences for
vulnerable groups of women;
• focus on specific cases of violations, such as those that expose systematic discrimination in access
to medicines, for example HIV/AIDS drugs, or to reproductive health services, for particular
groups such as women living in poverty, in rural communities, and adolescents;
• lobby public’officials who are responsible for the adoption and implementation of legislation,
including parliamentarians, and national and local government officials, in order to integrate
international standards and obligations of the right to health into national legislation;
• advocate the use of human rights standards as a framework for national and sub-national healthrelated policies and programmes that predominantly affect women and girls such as those
related to reproductive health;
• carry lout communication campaigns including: radio, television, or newspaper campaigns;
poster campaigns; and public meetings, which are especially important where populations are
functionally illiterate; and
• mobilize the public by promoting civil action, including letter writing/email campaigns,
petitions, and public demonstrations. Such civil action might be directed at, for example, the
remedying of specific violations or the introduction of mechanisms to protect and enforce the
right to health such as a patient or health ombudsman.
1
The following two examples illustrate ways in which an NGO might successfully integrate complementary
political and legal advocacy strategies. In each case, an NGO participates in judicial proceedings and, in
conjunction with this, successfully uses the legal suit to raise public awareness about the right to health.
Case study 10.4.1
I
I
In response to the South African government's Me4) tties and.Related Substances Control Amendment Act
(Medicines Act), 39 pharmaceutical firms bre ight ah ; action through the Pharmaceutical
Manufacturers' Association (PMA) in 2001' to try ari force the government to withdraw the measure,
fhe purpose of the Act was to make drugs more aff< dabl^ by allowing proprietary medicines, mainly
those prescribed for the treatment of HIV/AlDSz :o he substituted by far less expensive generic
equivalents or by cheaper drugs imported from abroad, as well as to improve the efficiency of the
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Medicines Control Council by introducing a pricing committee that could force pharmaceutical firms
to justify their prices. PMA claimed that the measure was tantamount to allowing the government to
expropriate or confiscate the property of pharmaceutical firms.5
The Treatment Action Campaign (TAC) applied to, and was accepted by, the Court to be admitted as
amicus curiae (friend of the court, or interested party participation) during the hearing. As a result TAC was
able to submit evidence to the court on behalf of people living with T1IV/AIDS (PLWHA). The petition
highlighted the right to health along with a number of other health-related human rights. TAC was also
instrumental in attracting massive national and international publicity to the case and called attention
to the right of access of people in developing countries to essential medicines and affordable drugs. The
PMA eventually withdrew application against tire South African government unconditionally, largely
as a result of the negative publicity attracted by the.case. (See section 10.9 for a related case about TAC)
For further information, see wdw.tac.org.za
Case study 10.4.2
,. U1,
ai) action was brought in the United States against the oil company Texaco by independent
>3 lawyers using information collected by the Centre for Economic and Social Rights (CESR) and a number
of other NGOs, on behalf of Ecuadorian plaintiffs, as part of a campaign to protect the health of
indigenous peoples living in the Ecuadorian Amazon from the adverse effects of exploitative oil
interdisciplinary team, including physicians, had worked together before the court
. > hearing in order to gather the necessary evidence and to launch an advocacy campaign. CESCR and.its.
partners used the lawsuit to raise awareness about the. right to health and mobilize public activities,
concerning the negative impact of oil development on human rights, including the right to health. They
held workshops that initiated the formation of a coalition, called the Amazon Defence Front, to support
the Texaco lawsuit and to advocate against the oil companies' practice of irresponsible dumping. In the
words of tire director of the CESCR Ecuador office, "The US-based lawsuit against Texaco has probably
done more than anything else to raise the profile of the oil problem and to change the terms of the
debate from one of government needs and environmental problems to one of rights and violations. ...
[l]he suit has reinforced the idea among the Ecuadorian public that 'rights' are at stake and that the
industry has been acting with irresponsible double standards".7
For further information, see www.cesr.org
h
Case study 10.4.3
In 2001, over two thousand health care providers/ patients, and social justice activists gathered in a
hospital run by Partners in Health in the village of Cange, in rural Haiti, to discuss the right of the poor
to survive. For this occasion, a group of about. ’60 people living with HIV prepared a declaration
regarding the right of poor people with AIDS to modern, effective therapy. The Crn^e Declaration was
presented at the conference and has siiue been.invoked as a model of a rights-based approach to AIDS
treatment as articulated by patients living in poverty. The following are excerpts from the Cange
Declaration:
'
'When we the sick, who are living with AIDS, speak on the subject of Health and Human Rights,
we are aware of two rights that ought to be indivisible, inalienable. Those who are sick should
have the right to health care. We who are already infected believe in prevention too. But
prevention will not cure those who are already sick. We need treatment when we are sick, but for
the poor there are no clinics, no doctors, no nurses, no health care. Furthermore, the medications
that are available are too expensive...
' ,
'
The right to health is the right to life. Everyone has a right to live. That means if we were not
living in misery but in poverty, we would not be in this predicament today. Having no resources
is a great problem for poor people, especially for-women and those with small children. ...
We pledge to remain steadfast in this fight and never to tire of fighting for the right of everyone
to have necessary medications and adequate treatment'.
For more information see wiuw.pih.org
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10.5
Promoting capacity-building among health professionals and
conformity with the right to health in service delivery
National and international medical organizations and associations of health professionals play a highly
important role in the realization of the right to health. This can happen in many ways, for example through
curriculum development, training and awareness raising; through witnessing and reporting of abuses,
through lobbying Tnd influencing of policies and budgetary priorities; by helping to define and monitor
compliance with national indicators and benchmarks; and in the implementation of service delivery, ^ough
research and publication, medical professionals also make a valuable contribution to clarifying the content
r
1
and meaning of the right to health.
As a noteviiorthy example, the British Medical Association (BMA) has published a highly-acclaimed book. The
Medical Profession and Human Rights: Handbook for a Changing Agenda (2001) which explores the interface
between medical practitioners and possible abuses of human rights, as well as the promotion of human rights.
It contains'comprehensive information on a wide range of human rights issues that health practitioners are
likely to encounter including refugees; asylum seekers; organ transplantation; torture; ethics, forensic science
and the promotion and projection of the right to health. The publication examines the ethical problems that
Health professionals can encounter in their professional practice and provides guidance on how to deal i
them It also includes specific recommendations with each chapter.
(he obligations and standards of the right to health of individuals and commumties. Health services that
comply with international standards of the right to health must:
. be comprehensive and accessible, both financially and geographically;
. be private, confidential, and respectful of the dignity and integrity of the patient;
. be of the highest possible quality and culturally acceptable; and
. provide individuals with information they can use to make their own choices.
Communitv-based NGOs might consider focusing advocacy activities on the promotion and protection of the
right to health at the institutional level, including those that deliver health care services to local populations.
Such activities include:
• targeting specific institutions to change their policies or practices, focusmg particularly on
discrimfnation against the poor, vulnerable, and otherwise disadvantaged groups^
Kscrimtaation often occurs at the institutional level, in administrative practices and in the
'unofficial' ways that policies are carried out;
• lobbying for greater transparency in budgeting practices;
. promoting services that are culturally appropriate to local populations, as well as appropriate for
vulnerable groups such as adolescents; and
.
. promoting improved training for medical and other professionals, including education m health
and human rights.
The case studies in the following illustrate the range of possible activities that can be undertaken by health
professional organizations and NGOs involved with service delivery.
Case study 10.5.1
.. A regi^a! health and human rights conferencejor healtlr ^ce^students,
As50ciat,con°n Aplicacitin
f0rHea'then Salud, or 'EDHU
(A<nnaci6'n Civil varn la Educaci6n en Derechos Huinanos
I
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< h i-
seg==i§sss
human rights, including the right to health.
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During the follow-up to the conference, the group carried out a study of the curricula of all medical and
nursing schools in Peru in order to evaluate their human rights content. The results will form a base
line for lobbying to promote greater inclusion of human, lights in the curricula for medical and nursing
training.
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For further information, see www.edhucasalud.org
Case study 10.5.2
The International Council of Nurses (ICN) is a federation of national nurses' associations (NNAs) from
more than 120 countries. The ICN Code of.Eftic^for Nurses incorporates the central notions of health
as a fundamental human right and that respect for human rights is inherent in nursing practice. Many
ICN activities focus on promoting a human rights approach to health, including a series of fact sheets
and policy statements that explain the human rights framework and set out strategies to promote the
right to health. The following is an excerpt from an ICN Fact Sheet on health and human rights:
I
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"National nurses' association (NNAs), individual nurses and other health care providers must play a
leading role in strengthening the vital link between health and human rights and thereby contribute to
prevention of disease and enhance equitable access to health care. More specifically NNAs, nurses and
other health care providers need to:
• develop understanding of the human rights,declarations and instruments;
• create awareness about the vital link between human rights and healtlr and tire harmful impact
of human rights violations on health;
• work with the media, human rights groups^^lawyers' associations, women's associations and
policy-makers to heighten awareness about the rights approach;
• use specific examples of human rights violatioirs such as gender discrimination, FGM/C and
other forms of violence to demonstrate.their.harmful consequences on health;
• mainstream human rights and ethics education into all levels of nursing curricula;
• lobby for equity and universal access to comprehensive, cost-effective and affordable health care
for all people;
• monitor impact of healtlr reform mechanisms such as user fees and cost sharing on access to
health care and other social services."
V An "
For further information, see wivw.icn.ch
'V
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Case; study 10.5.3
' The American-based International Anti-Povery Law Center (IAPLC) and the Netherlands-based Johannes
bWier Foundation for Health and Human Rights have drafted a set of preliminary guidelines to assist health
professionals in monitoring, promoting and protecting the right to health. The Guidelines for Health
Professionals on the. Right to Health are based on CESCR General Comment 14 on the right to health and
propose formal systems for incorporating human rights monitoring into the work of health providers.
In May 2002, the Guidelines were presented and discussed during a meeting of the International
' Federation of Health and Human Rights Organizations (IFFHRO), a network in which the Johannes
’ qV/ier Foundation participates, at which it was decided to forward tire guidelines to component
members of the network.
For further information, see wwio.iaplc.org
IfIII
Cnse study 10.5.4
The Commonwealth Medical Trust's (Commat) main objective is to promote an ethical and rights-based
approach to the sexual and reproductive health. of tire poor and otherwise vulnerable and
disadvantaged groups in dcy£l£$ngcimnUi£^^
ethics, with humarurights
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and in 1999 it published a Training Manual dn f^aCm! H,lmn,r Rights Standards for Health Care
haVC
connhKs and " hXhaX^tXvXnfoiyin umfonh S
ragio™! workmg groups for training medical and other health professionals in a nghtlbased appro'a A
S’nXrTt r°SIly
UTPA'
mOnit0rinS committees and concerned NGOs such
at onal medical and other health professfonal associations. In New York in 1999 it held
1
& W0inCn'S Hcn"h'inclitdi^ Sm'al & productive I lealfh as aHuman^hf
at uhich a Declaration on the topic was unanimously agreed by the distinguished mrH
'
attended. The following are two extracts from the Dedaration:
' 8
participants who
I
;The health status, including sexual and reproductive health, of women (including the girl child)
is adversely affected by a wide range bf humdnirights violations. Health professionals are well
placed to detect many such, violations Accordingly, the bodies responsible for producing and
enforcing ethical guidelines for health professionals should take account of provisions concerned
wnh women s hea th and rights, including sexual and reproductive healtl/and rights in the six
major international legally binding human riglits'ffetitiOs": fo ■:
'
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"HeaUh professionals who become aware of hurrian rights violations adversely affecting
adversely affecting
women s health have an ethical obligation to'report them through their health professional
association, organization or authority, as appropriate. The participation of health professionals in
any practices and procedures that are harmful to women or violate their rights such as FCC
cannot.be jl'^ified on grounds that their involvement U-ottld make the procedures less dangerous
'
m”'e
l,Se "
t0lreSpeCtab,e and
'
’
'' ’ y.: 'ro-. For further information, see. www.commat.org
Case study 10.5.5
'
£,^l'L0 uk (PHRnUKHrk
!K,'7n riShts cd«“tion for docton!, fViysicriiis Io,
llaJ launched a global campaign to integrate health and human rights‘ih
dergraduate and postgraduate medteal training. The campaign has included the presentation df4
parallel (shadow) report to the CESCR in 2002 which cites evidence of discrimination; including
disparities m treatment, by UK doctors against particular groups of patients. (See chapter 11.) The PHIU
yjtXn
3 v “ n8
1ad°PtiOn °f a" ethiCal C°de in hosPita’*'
schools and general
practice based on key human rights instruments that are relevant for medical practice. One proposal is
matsuch a code could affirm a commitment to support the sections'of the UDHR and CESCR General
Comment 14 that define patients' health rights and provide inspirational and practical advice for
everyday medical care."" PHR-UK has also developed an internet-based course. Medicine and Hu,^
ava labb fo0? e
? modu’e/includin8 ,ecture
student handouts and case studies, is
edi
i ha1S1been "sed 1,1 UK medical schools- Included in its other activities aimed at
educatmg doctors in health and human rights are: study, days on Medicine and Hun,an Rights; a Health
and Human Rlshts course (approved as 'continuing medical education' by'the Royal College of
Physicians), and the provision ot training on the right to health for the staff of international human
rights and international health NGOs.
.
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For further mforniflfion see www.phruk.net
I
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Case Study 10.5.6
with a focus on remedying inequalities in acdess to health care services. One example of their work
concerns a mulh-faceted campaign by Partners in Health and its sister organization in Peru, Series ™
Snhul, to improve access of the poor to treatment for multi-drug-resistant tuberculosis (MDR-TB) in
slum areas of Lima, Peru. In the course of its work, Socios Cn Salud provided direct medical services to
those being denied it and engaged in political advocacy at the national and international levels to bring
about policy changes needed for a sustainable and long-term solution to the problem. Not only did the
NGO provide comprehensive MDR-TB treatment for the poor in slum communities, but it influenced
118
the Peruvian government to change its public health policy regarding such treatment and also
a significant role in persuading the WHO to modify its policy guidelines in favour of providing MDRTB treatment for poor-peoplerRather-than*using“COst-effeetiveness arguments to plead its case in favour
of policy change (with calculations to prove that not treating MDR-TB patients would ultimately cost
more), the NGO based its advocacy on an explicit human rights perspective. They did so by insisting
that the benefits of scientific progress, including access to the highest attainable standard of care, shoulc
be available to all on a non-discriminatory basis without regard to their economic status oi-jability to
pay for such treatment.9
For more information see ^oww.pih.org
10.6
Building coalitions and forming networks
The political and institutional sustainability of human rights based health policies and programmes requires
that there be a constructive and cooperative relationship at national and sub-national levels between state
authorities, health professional associations and health advocates. (See section 10.2.)
I
It is also important for NGOs to network independent of government authorities, in order to form political
coalitions and lobby in support of the reform of policies and the remedy of violations. For this purpose, inter
disciplinary alliances involving health professional associations; other NGOs workirig on health-related
issues; grassroots health groups; health service delivery organizations; and human rights groups should be
encouraged to promote the advancement of health rights within and across national borders.
Case study 10.6.1
In 2001, the NGO Physicians for Human Rights - USA and the Francois-Xavier Sagnoud Centre for Health
and Human Rights at Harvard University organized a network of physicians, nurses, health
practitioners, health administrators, relief workers, human rights professionals, ethicists, scholars, and
activists from all over the world to draft a consensus document, entitled the Declaration on Human Rights
and Health Practice.
The purpose of the Declaration is to clarify the relationship between health and human rights and the
responsibilities of health practitioners to protect and to promote human rights. The first draft of the
Declaration was prepared by more than 75 experts in health and human rights from 40 different
/countries. The drafting process calls for continued expansion of regional representation and consensus
■building, and for the endorsement of tire final document by international health and human rights
organizations such as the United Nations, the World Health Organization, the World Medical
Association, and by health professional associations.
For further information, see wwuKhsph.harvard^du/fxbcenler/
Case study 10.6.2
In Peru, the Association for Human Rights {Asociacion pro Derechos I himanos, or APRODEH) is working to
improve broad-based community participation in" health policy and programming.’1’ APRODEH
focuses on building coalitions and providing opportunities for dialogue between civil society and
government about health priorities and possibilities for rights-based strategies. This departs from the
adversarial role toward government traditionally adopted by the human rights movement in Peru. One
of APRODEH's activities has been to organize workshops in urban and jungle regions of the country.
These have brought together national and regional government health sector officials; representatives
of the Human Rights Ombudsman; international donors and agencies; NGOs offering health services;
health and rural development NGOs; local health providers; activists from different fields; community
health workers; representatives of patient organizations; and human rights activists. Workshops have
allowed stakeholders from civil society both to articulate what they seek from the government in terms
of recognition, support and relationships/and to'djscuss ways to improve community participation in
decision making. One important, conclusion that has emerged is that incorporating a human rights
perspective in health programmes requires changes both in the working conditions of many health
workers and in health education.” The workshops alsp focLis on eliciting from multiple perspectives
119
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"the priorities and needs of the different areas of the country, with respect to the four dimensions of the
right to health, as set out in ICESCR".12
For further information, see www.aprodeh.or^.pe
Promoting sexual and reproductive health rights
10-7
How have NGOs contributed to clarifying the meaning and content of the international right to health with
regard to sexual and reproductive health rights?
I
I
Some of the most successful work by NGOs using a human rights approach to health has been on women's
health rights, sexual and reproductive rights, and the health of the girl child. The fact that these particular
aspects of the right to health have now been worked out in some detail can be attributed largely to the
effective advocacy strategies adopted by women's NGOs concerned with health. Recognizing and
capitalizing on the benefits of placing health issues firmly within a human rights framework, women's groups
from around the world played a very active role in the ICPD and FWCW and their follow-up reviews by the
UN General Assembly. They made a major contribution to the development of the concept of reproductive
health rights, highlighting the importance of particular issues, such as the reproductive health rights of
adolescents.
Women's groups across Latin America, for example, organized themselves into networks and played a major
role by drafting and proposing texts and by pressuring their governments both before and during these
important conferences. Women's NGOs have also capitalized on the benefits of working on health issues
within a human rights framework by publicizing and monitoring the commitments made by their
governments and by promoting their enforcement.
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Case, study 10.7.1
Hie International Planned Parenthood Federation (IPPF) Charter on Sexual and Reproductive Rights was
published in 1996. It provides an ethical framework within which IPPF carries out its mission, and ,
clarifies the basic human rights of individuals within the sphere of their sexual and reproductive lives?'
The Charter is based on twelve rights, which are grounded in core international human rrights’
instruments, together with additional rights that IPPF believes are implied by them, and it represents
IPPF's response to the challenge of applying internationally agreed human rights language to sexual
and reproductive health and rights issues. By drawing on relevant extracts from international human
rights treaties, the Charter demonstrates the legitimacy of sexual and reproductive rights as key human
rights issues. The Charter has been designed as a tool to help NGOs to hold governments accountable
for promises they have made to uphold human rights in general, and sexual and reproductive rights in.
particular.
The Charter has three key objectives:
• To raise awareness of the extent to which sexual and reproductive rights have now been
recognized as human rights by the international community in internationally adopted UN and
other declarations and commitments;
L• To clarify the connection between human rights language and key programme issues relevant to
sexual and reproductive rights; and
• To increase the capacity of NGOs to make use of human rights processes.
The Charter demonstrates, for example, that the basic human right to information and education can
be used to campaign for the right of adolescents to sex information and education services. In. terms of
making the connection clear between human rights and sexual and reproductive health and rights
issues, for example, it links the human right to privacy, with the right of all sexual and reproductive
health care clients to services that respect their confidentiality.
Ct •
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The Charter is also intended to help NGOs to use international human rights processes to advance
sexual and reproductive health and rights. The Charter is now available in more than 25 languages..
IPPF has subsequently published Guidelines for the use of the Charter, which explain how the document
can be used to campaign for improved sexual and reproductive health and rights. Both tire Charter and ■
the Guidelines now form part of the IPPF Rights pack. The latter also includes a booklet of facts with
J
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statistical information a programme examples for each of the 12 Charter Rights; and three posters
featuring the Rights of Young People, the Rights of the Client, and the 12 Charter Rights
For further information, see www.ippf.org
I
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Case study 10.7.2
In 1998, the Latin American and Caribbean Committee for the Defense of Women's Rights (Comitt de Amercia
Latina v el Caribe para la Defensa de los Derechos de la Mujer, or CLADEM), a regional network of women's
.rights groups, initiated a process of producing an Inter-American Convention on Sexual and Reproductive
Rights^which includes provisions on the right to health. CLADEM's intention is that the Convention
should fill "a vacuum regarding sexual and reproductive rights within the Inter-American human
rights system, in which virtually none of the new gendered understandings of human rights [advanced
.by the world, eonferen.ces] have been incorporated. The CLADEM project also seeks to strengthen
• 'regional mechanisms and set out or clarify regional standards because national legislation relatmg to
reproductive rights in Latin America tends to be weak and subject1" to shifts based on political, whim.
The project began with regional consultations; the initiation of an alliance with other NGOs and
networks in Latin America and the Caribbean; the preparation of an Ethical Framework and a
Manifesto on sexual rights and reproductive rights; and the development of a webpage.
For further information, see www.cladem.org and www.conveiicioii.org.uy
Case Study 10.7.3
II
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The Women's Global Network for Reproductive Rights (WGNRR) launched its Women's Access to Health
Campaign (WAHC) in May 2003. The campaign, is based on two major documents: the Alma Ata
Declaration, adopted in 1978, with its; emphasis .on primary healthcare and the People's Charter for
Health (see case 10.6.4), as a framework to elaimThe: right to health as a basic human right. The
campaign focuses on women's enjoyment of t}.ieir_ sexual and reproductive rights and on the
responsibility of government for women's healtlazThe'main objective of the campaign is to provide
tools and information to help groups tOTm$F^^en<rs^“OTT
and’to lobby their governments at
all levels.
i C
The theme of the 2003 campaign was 'Governments, take, responsibility to ensure women's pccess to health'.
Throughout the .campaign, WGNRR collaborated witli grassroots groups and NGOs in Africa and the
other regions of the world, each group being free to organize its own activities within a broad
framework. Examples of NGO activities1 within the Women's Access to Health Campaign include:
• popularizing the Alma Ata declaration on Health for All and bringing women's perspectives to
bear within it;
• using the People's Charter for Health to mobilize and educate community members, policy
makers, and government representatives,about the right tp health, and as an advocacy tool at the
local, national and international levels;
• advocating for government representatives at village, district or national levels to improve
primary health care provisions within the.Alma Ata Declaration, keeping women's health needs
a priority;
■' a '• -
"■ 'if
• demanding that governments ratify and abide.by the Women's Convention;
• joining up with other' groups wiirkih^^
with them at all levels; and
•
the demands listed above
‘ •
• documenting how primary health care is being implemented in diverse communities, regions
and countries, and how reproductive and sexual health rights are (or are not) being integrated
into such services.
: '’ . .
- .Forfurther information, sec zoww.wgnrr.org
; Fhe Peoples Charter for Health is available at www.phmovement.org
m .. ..a
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Case study 10.7.4
The International.-Programine on Reproductive and Sexual Health Law at the University of Toronto Faculty
of Law and Action Canada for Population and Development (ACPD) have jointly developed a publication
entitled 'lhe Application of Human Rights to Reproductive and Sexual Health: A Compilation of the Work of
International Human Rights Treaty Bodies. It includes relevant updated selections related to reproductive
and sexual health from the concluding observations and general comments (or general
recommendations) issued by UN human rights treaty bodies. The publication is designed to assist both
governments and NGOs in compiling reports on compliance with, and violations of, the right to sexualand reproductive health; and to assist with the preparation of related advocacy manuals, training
programmes, and research protocols.
To view the compilation, see www.acpd.ca/coippilations:To order a CD-Rom version, email info@acpiLca.
10.8
Advocacy efforts related to international obligations arising
from the right to health
NGOs can undertake a number of activities in relation to
obligations of international assistance and cooperation. (See
legal victories relating to the right to health attain a
chapter 6.) These include:
greater significance when they are accompanied by
• advocating against any international assistance and
other actions aimed at raising public awareness, and
cooperation policies, including bilateral development aid
when civil society assimilates those victories into
and lhe lending policies of international financial
their understanding of their own entitlements. ... The
institutions (IFIs), that have the adverse effect of
more people receive remedies for violations, the
inhibiting a recipient state from complying with its core
more they perceive the right as real; the more people
obligations arising from the right to health;
perceive the right as real, the more they clamor for
• working to ensure that greater attention in donor and
remedies'.1'1
lending policies is paid to the conditions that have an
adverse effect on the provision of health services for the
poor, vulnerable, or otherwise disadvantaged groups, such as the introduction of user fees;
• advocating that priority in the provision of international medical aid, financial aid, and
distribution and management of resources, including potable water, food and medical supplies,
should be given to the most vulnerable groups of the population;
• campaigning against embargoes or similar measures restricting the supply of adequate
medicines and medical equipment to;
• highlighting and campaigning against international trade agreements that have an adverse effect
on the enjoyment of the right to health, particularly for developing countries and the poor,
vulnerable, or otherwise disadvantaged groups in such countries; and
• promoting implementation of the Doha Declaration.
I
Case study 10.8J
The Women's Rights Watch project of the Humanist Committee on Human Rights (Humanistisch Overleg
Meiisenrechten, or HOM), an NGO based in the Netherlands, is developing a gender and human rights
impact assessment. HOM use the Convention oh the Elimination of All Forms of Discrimination
Against Women as its basis and has chosen health as the theme for its pilot project. The aim of the
impact assessment is to assist policy makers assess the possible impact of new or changed development
policies that impact upon women's right to health.
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HOM will also use the Convention as a framework to list.and prioritize issues that affect women's right
to health that should be included in development policies; HOM co-operates with women's
NMMMVoni
NGOs fn
Asia, Africa and Latin America, to ensure that the results of, its project and strategy can be made use of
in both the South and the North.
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Tor further information, see www.hom.nl
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Case study 10.8.2
International Day of Action for Women's Health for 2002 (May 28) focused attention on' the effects of
SmaSSde ag/eements on women's rights to health. KULU -Women and Development, an NGO
.fc“eXrk, supported the campaign with activities aimed at raising pubhc awareness of the
issue KULU emphasized two messages: first, that women are almost invisible m international tiade
nereements and secondly that such agreements and associated liberalization policies have enormous
XrTcXuSui^ right to health of poor women in developing countries, as essential.
SOsuSSL andean water are increasingly becoming a market-governed privdege.
Included among KULU'S activities were a public meeting to discuss
^reement on Trade in Services (GATS) for womens rights to health care sei vices and postca
, -, a campaign that publicized the following messages:
; . HIV infection from mother to child could be avoided if pregnant and breastfeeding mothers
receive HIV treatment;
. Women and the poor in developing countries must have access to HIV/AIDS treatment and
essential drugs; and
• Trade agreements must respect the right to health and life.
n
For further information, see www.kulu.dk
10.9
Working with national and regional enforcement procedures
to ensure state accountability
'States have an obligation to take steps, individually
A human rights approach to health must emphasize that states
are accountable for complying with their international, regional
and national obligations arising from the right to health. (See
chapters 1 and 2.) Working to establish legal and other
appropriate remedies for violations of the right to health is
therefore critical to its promotion and protection. Accountability
mechanisms which may be available to hold states accountable
for failing to give effect to their human rights obligations
include tribunals, parliamentary processes and relevant
ombudsmen offices such as a health ombudsman.
and through international assistance and
cooperation, towards the full realization of the right to
health. For example, States are obliged to respect
the enjoyment of the right to health in other
jurisdictions, to ensure that no international
agreement or policy adversely impacts upon the right
to health, and that their] representatives in
international organizations take due account of the
right to health, as well as the obligation of
international assistance and cooperation, in all
policy-making matters.’
It is important that NGOs take every opportunity to bring cases
of actual or potential violations of the right to health to national
Special Rapporteur on the right to health’■
and/or regional courts and other available complaints and
enforcement mechanisms, either by invoking the right to health
directly or indirectly, or another health-related human right that
. .
.
.
is protected in national and/or regional legislation (including guarantees of non-discrimination). Successful
legal suits can establish judicial precedents and can be coupled with media campaigns that educate e pu ic
about the right to health and government obligations.(See chapter 6.)
There are increasing and encouraging examples of NGOs successfully arguing cases in national courts that
concern violations of the right to health. Although many NGOs will not have the resources (staff, financial or
otherwise) to pursue legal remedies on their own accord, it is important to know that there can be
opportunities to contribute to cases brought by others. For example, if a relevant court proceeding is taking
place, health professional associations and NGOs can sometimes provide courts with amicus curiae (friend of
the court) briefs that present (outside) expert information to the court. (See case study 10.4.1.)
Case study W.9.1
In Argentina, a domestic legal suit (umpuro^ was successfully brought in 1998 by the Ar^entme Centre
for Legal and Social Studies (Centro de Estudios Legates y Sociales, or CELS) on behalf of 3.5 million people
to force the government to manufacture and distribute a vaccine against a disease that exists only in
Argentina and is often fatal (Argentine Hemorrhagic Fever). "CELS argued that, given that rapid
diagnosis of the disease is difficult and it affects a population that does not have easy access to medical
services, the most effective means of combating the disease is the administration of a vaccine. In a
123
I
I
1
I
p|U m r Je (“Ourt dnectly applied international treaty norms regarding the right to health an 11
i
international human rights documents irttowh“* —porates these
■to'
:For further information, see wwio.cels.or^.ar
Case study 10.9.2
Ihnt n eounlrj-wide MTCT prevehUon programme is an Ineluewble obligation of"ibe State
ssss Sti" 5°,v“po,icy
andbaa
•h' -"ssss-sz
J'« ItUfJ pagd the government "to make Nevirapine available to HIV positive svomen ,vlto eivk
i h in the public sector, and to their babies, in public health facilities."21 The judge also found thafthe
government had vtolated section 27 of the State's Constitution, which grtaranteef access to healfo cfi '
^ttesaShbir16 n8ht ? reprodyctive health care'in that if had not taken reasonable measufos
ithm its available resources to provide women with access to MTCT prevention programmes.
:. f
lhe South African Government appealed against the judge's ruling to the constitutional court which
uined down the appeal m July 2002 in a ruling which went even further in favour of TAc’ln this
witfon ifoavaifable tlOnn C°Urt
*e SovernmGnt is paired to "devise and implement
thm its available resources a comprehensive and co-ordinated programme to realize the riehts of
ChMreT0 have “ tO hXlth services
chi d transmission of HIV. The programme to be realized progressively within available resources must
XSeTrTma it6 meaSUre^ for,COunseninS and testinS P^gnant women for HIV, counselling* HIV-’
toanXissfoh of H VV°nTn v" ' °Pt,OnS °Pen t0 ‘hem t0 reduCe the risk of ™ther-to-child
Cowt)r,!C!/ m SMt ‘ A nCa (IDASA)'lntervened in *6 constitutional case as amici curiae (friends of the
For fnrther informa tian, see coww.tac.or^.za
I
i
I
Case study 10.9.3
In Venezuela, Prove,, (Pragma Venezolano de Pducec^'AcMen Derechos Humanos) successfolly sought
domeshc legal recourse for eolations of the right to health on behalf of a group of approximately 600
chddren with congenital cardiac disease. In 2001,; Proyea presented a legal action at the Venezuelan
court (children s division) against the metropolitari mayoralty, which is the responsible organ of the
hosp.tal hat was attending to (he children. ProVea.argtied that this group of children were receiving
inadequate care and suffering violations of their right to health” on the following grounds- that the
ZavS^
W fS 10010n8'
Children waiting at the time o^Z^tSt
the average waiting time for surgery was too long, between two and three years; and that the hospital
demanded payment of 1 million bolivares (equivalent;fq approximately US$ 1500) from the children's
relatives for medical supplies, despite a provision in the Venezuelan Constitution that establishes free
medical care m -the public system. The.court found in Provea's favour and ordered that medical
supplies and equipment be provided for'the ho^pi&l's'suigical unit and be designated for the purpose
of cardiac surgery and that the Venezuelan Ombudsman must coordinate negotiations 0>,esa dediaLo)
to find concrete solutions to the problems. :
' :i‘ '1 ’
The subseqnent negotiations achieved a number of agreements, including the following: agreement to
increase th<l; number of surgeries per week; to hire nurses for the cardiac operating room; to remodel
124
•DO
■ ■ new equipment to the omtlotogy mu' m
p^e^wport^therwhile most of these
and supply
zk- «•.>*'a— • ">“'i ««*•
judgment in relation to those which were not complied wit .
http^llwww.derechos.or^.ve
For further information, see
Anotable example of NGOs using a
Nigerian National
to health involves a case concerning the Ogom people n g
Company to develop o.l
Petroleum Company (NNPC) formed _a
• - in the Delta region of Nigena with the N
J.nHnnq and faulty infrastructure had led to
allegation that a combinationurf
waterways, with heavy contamination of
S^T^ulS0to mZve health, environmental and social problems among the local
and failed to enforce safety measures ^^Ston^d
v
military government had condoned and fac 1.1 d h
wjth complaints from local
legal and military powers of the state at their
p
•
violence, and executions of Ogoni
communities, the military regime had respon c
. iggafco^gel, Kcn-Saro-Wiwa, the leader
leaders. After months of imprisonment,
J" , (MOSOP) had been tried and convicted on false
of the Movement for the Survival of the Ogom People (MOSOP) had been ti
charges, and had been executed along with eight OLIlCl
other vygwi
OgoniU UVU ...
I
eSi: ^=5===
"i^Tan.l S.c«l RI8M> (CE» »
r±miCston handed down a historic decision that concurred with the a.PPh"b^ of
of
enjoy tire best attainable
the African Charter on Human and People s Rights, including tie ng
standard of physical and mental health.24
• i on SERAC and CE$R u
™
For further information
including the full texts of the NGO coinniumcatioii
and the Commission's decision, see wwto.cesr.orglESCR/africancommissionJUm
i
Notes
Y„„n A. «.~8 .»<> P—8 «» "S"> » “h ”
A”““ H“1"’ "d H““ KSh“
.
1
2
Yamin A. Challenges and possibilities for innovative praxis in health and human rights: Reflections from Peru.
3
4
5
Healtli and Human Rights. 2002:6(1 ):44.
Yamin A. 2000. Ibid:133.
,
An important recent development refaUng specifically to 1^^d
Organization's (WTO) Doha Declaration which addresses the WTOtllc WTO p^ssed a rule
countries' freedom to take measures to improve access to "al medianes. ^8“™ the d
Pt0 countrics
that allows WTO member countries that produce generic copies o pat
g
P
f’iedicineS als0
Sit-xs zass:s~ y -——
Compact is an “ample of an important international initiative in this area. (See chapter 6).
125
cHl
[
l
I
1
6
Yamin A. 2000. Ibid:132-135.
7
As quoted in Yamin A. 2000. Ibid:132-133.
8
Hall P. Doctors urgently need education in human rights. The Lancet. 2002 Dec 7, (360): 1879.
9
Case study description based on Yamin A. 2002. Ibid:43-44.
10
Case study description based on Yamin A. 2002. Ibid:45-49.
11
Yamin A. 2002. Ibid:48.
12
Yamin A. 2002. Ibid:47.
13
Yamin A. 2000. Ibid:120-121.
14
Yamin A. 2000. Ibid:128.
15
Hunt P( Report of the Special Rapporteur on the right of everyone to tlie enjoyment of the highest attainable standard
of physical’and mental health . E/CN.4/2003/58: para 28.
16
This legal mechanism, called an accion de amparo is the primary means of protecting an individual's constitutional
rights in many Latin American countries. It is important to note that there are wide variations in the use of the
amparo, such as in the scope of protections offered and the procedures for obtaining it. However, it is being used
byNGOs in many countries in the region as an effective legal tool. In most countries in Latin America, suits that use
the amparo recourse are limited to establishing or remedying the situation of the individual plaintiffs before the
court, as dpposed to representative actions which grant general, positive relief. (Adapted from Yamin A. 2000.
Ibid:124-125.)
17
Case study description based on Yamin A. 2000. Ibid:125.
18
Causa No. 31, Viveconte, Mariela Cecilia c/Estado Nacional — Ministerio de Salud y Accion Social, s/Amparo Ley
16. 986. Cdmara Nacional en lo Contencioso-Administrativo Federal, Sala IX Jun. 2,1998. As cited in Yamin A. 2000.
Ibid:n34 and n36.
19
Minister of Health v Treatment Action Campaign. High Court of South Africa, Transvaal Provincial Division. Case
No: 21182/2001.
20
Ibid.
21
Ibid.
22
Provea invoked right to health provisions in the Venezuelan Constitution, the Venezuelan Organic Law of the
Protection of the Child and the Adolescent, ICESCR, and CRC.
23
Case study description based on excerpt from Submission to the African Commission on Human Rights as
reproduced in: International Human Rights Internship Programme. Ripple in still water: Reflections by activists on
local- and national-level work on economic, social and cultural rights. Washington, DC: International Human Rights
Internship Programme;! 997: 107-113.
24
Communication 155/96, SERAC and CESR v Nigeria, Fifteenth Annual Activity Report of ACHPR, 2001-2002, Annex V.
126
^72-
THE ASSESSMENT
OF THE RIGHT TO
HEALTH AND HEALTH CARE
at the country level
A People's Health Movement
Guide
October 2006
J
1
PHM .or—,.
o—0™'
Spi-»..
deserve more than half the praise or what is found hereafte .
I
—>*='»*
w
1. Introduction
The People’s Health Movement (PHM) Right to Health
is designed to focus national
in^atl°
sma|| shift of resources. Using this guide
step in the campaign.
m
[Note: Bolded words and phrases are defined in the Glossary in Annex IV],
The RTHHC centers on the right to heaUh care
acheive health for all.
promotion of the Primary Health Ca^
^mpaign may also look at any other health issues
However, each country Pa^
^HC will denounce any documented violations of the
using the framework of the guide, ne k
determinants of health. Once your
right to health, includ!n9 ^ose r®
b°e Jsed in different ways, depending on the situation in
“ZX"
RTHHC process as sef oul in fhe campaign proposal
(See it at www.phmovement.org).
The main focus of fhis assessment H on go—<
Of five main questions you will be able tc' da^
™
yoplegYou wi|| [hen develop policy
fulfilling) its committments to
Jnational Inc?international levels during the latter stages
demands that will be presented at
non-State actors (such as corporations, or nonof the campaign. You can alsc> ch^
r0,e jn violations to the right to health. In that
governmental organizations) acc°unta^y/°HC
de the opportunity for claim-holders and
:s^^"--~"^toMtono,,hehea"h^or
1.1. Who can use this guide?
TNs assessment tool is designed for P™ nationai e“X^cXlgn^eSeisment
human rights organizations that will
process should be used to attract as m y P P
purpose is to get a country diagnosis of_how the ight t ^h
tQ
RyHHC lts
heglth care js be|ng upheld
governments for
for poor and marginalized PoP^latlonSn ■ t
t an overview of the status of the right to
corrective actions. For PHM, the purp’
fjve continents. This information will also
SXgSSeISXt™ eInternational level, and at WHO. to more actively advocate for
the health rights of the underserved.
J
1
2. Analysing the denial of the right to health and
health care
2.1. What is meant by denial of the Right to Health?
There is an existing body of international covenants and consensus documents which
mandates the Right to Health for all. Most country governments have committed themselves,
to varying degrees, to implement the Right to Health, including the right to health and health
care, by signing certain of these international covenants. Many national constitutions also
recognise the Right to Health and mention the obligation of the state to provide health care and
public health services.
The non-fulfillment of these state obligations may be considered a denial of the Right to
Health.To demonstrate this denial, essentially you have to do two things:
I
1. Examine the national level obligations of your government related to the Right to Health in
detail.1
2. Examine whether all these obligations are being carried out and, if not, determine what
characteristics this denial has in your country.
On the basis of this analysis, you can make recommendations for improvements that will lead
to a better implementation of people’s health rights.
2.2. How can you assess the denial of the right to health?
1
By following this assessment guide, you will be undertaking a five step process to document
most aspects of the denial of the Right to Health in your country. Moreover, you will be
proposing ways of improving the realization of this right for all.
The five key questions this assessment asks are:
I
I
I. What are your government's commitments?
II. Are your government’s policies appropriate to fulfill these obligations?
III. Is the health system of your country adequately implementing interventions to realize the
right to health and health care for all?
IV. Does the health status of different social groups and the population as a whole reflect a
progression in their right to health and health care?
V. What does the denial or fulfillment of the Right to Health in your country mean in practice?
These questions lead to the five steps we suggest you follow in applying this guide
2.3. What do the five steps assess?
STEP I. What are your government’s commitments?
In case your government has not signed a major treaty or covenant, you can still judge the obligations against widely accepted international
norms.
J
I
s====E=egovernment has not signed a particular covenant, this too needs to be noted.
f
The right to heatth an.
.rraccTs'to
i
to ^I, associate and assemhie. to human
dignity, to equal treatment, to non-discrimination.
STEP II. Are yJur government’s policies appropriate to fulfill these obligations?
are
]
violations.3
i
\he?fluerSe°'sn:upcTXS"B:ckx:dt9anXeSS^
I
agencies, should also be noted.
STEP hi. is the health system ot your country adequacy implementing interventions to
realize the right to health and health care for all.
You will look at the actual structure and functioning of the health system in your country, to
SBume^'ndoth^SSh^S
"tcTsfl^Zun^ton^mg^^
average health care expenditure
SSSs i===-i=K - ■
community, provision of relevant information and other as retevan
u,ar| ,he
XhSSaStC^cai industry, including price
control mechanisms.
2 Based on: ICESCRG^nVal Comment 14. paragraphs,3 and t8
3
violations of ESC Rights, paragraphs 14 and 15].
I
(o
people.s .gMs vjolations can occur
inequities. By comparing health
S”60'3'
are most
~ "’°Se Wh°Se hea',h ri£"’'S
mHoEIV' D°eS the.health status of different social groups and the population as a whole
reflect a progression in their right to health and health care?
Here, you will look at the ultimate impact the health system, and at how several of the social
eterminants of health are being addressed. More specifically you will review maior health
care of vMu'"
WhiCh "" te" y°U to what extent
Wo heafth and heaTh
™■ h hk ?r°UpS IS bein9 resPected and fulfilled. Health inequities will be assessed
y comparing health status indicators for the more privileged with those of the less privileged.
S?e?JC fu6 StUdieS Can provide rea|-|ife examPles
S2 (XT Care dUe ,0 eXiS,i"9 POliC'eS and'OT
how individuals
kiTprac\i^?at d°eS the denial °r fulfillment of the R'ght to Health in your country mean
ou,hned in
1 with the realities
s==^K~sS?SESF f
Lack of capacity in itself is no justification for bad or non-existent health nnliriAc tko
SESBEESEE!°
international assistance 6 Lack nf taqai
S °U
6 ICESCR General Comment 14. paragraph 18.
ICESCR article 2 and General Comment 14. paragraph 38.
911
exPanc^ ^e*r capacity by seeking
I
2.4. Before you start
Please keep the following in mind while carrying out the assessment.
,
to two months and provides comprehensive human
Time: A full assessment may take one
data collection is the most time consuming part of the
rights lobbying arguments. The d_._
process. Sound lobbying arguments need to be base on facts and not all the required
information will be readily available.
Selectiveness: You need to answer only the questions you find relevant for your own
assessment Questions that have little or no relevance to your country’s situation should be
skinned You can also be selective in the level of detail. Only go into detail if you expect that
(KrmaSonnecessary for your anafysis or lobbying. At
Al some points you may »anl
want to
..
.«
i
it- —
add questions that are specific to your situation.
I
"e neattb system you can buitd upon. Make a work plan to help organize the process you Wilt
follow.
You will need to involve people from within your organization and from other .^^atk^ns
means more lobbying power.
Findinq the information: You may find relevant information to answer this assessment's
health problems..
I
3. The Assessment Guide
Chapters outlined the main purpose of each step. The following section provides suggestions
for more specific questions to answer or issues to consider.
STEP I. What are your government's commitments?
International treaties signed by a government and/or ratified by its legislature are as legally
binding as any law. The commitments your government has made by ratifying human rights
reat|es often require changes at the national level. For instance, it must recognize the right to
health and health care in its political and legal system.7 It has to abandon any laws or
measures that have a discriminatory impact. Inclusion of the provisions of a treaty in national
legislation makes it easier for people to claim their rights.
Look in Annex III for references on treaties, consensus documents, and other agreements your
governement may have signed.
7
MAIN AREAS TO ASSESS
What international covenants,
treaties, and consensus
documents has your government
ratified/signed-on to?
ICESCR General Comment 14, paragraphs 34-36 and 60.
RELEVANT ISSUES TO EXPLORE
Which treaties has your country ratified? First consider
the major international treaties (ICESCR, CEDAW and
CRC) and regional treaties.
• Has your country expressed any reservations or
limitations on those?
(You can find information on treaties and
ratification on the websites of the UNHCHR,
www.ohchr.org/english/laW/index.htm,
and the Human Rights Library of the University of
Minnesota, www.umn.edu/humanrts/treaties.htm .)
• Which consensus documents has your country signed?
Millennium Development Goals (MDGs), Beijing
Platform for Action, International Conference on
Population and Development (ICPD), others.
• Also consider other bilateral or multilateral agreements
that may influence policy. For example, free1 trade
agreements allowing international companies to compete
with local industry (e.g., the GATS), agreements* with the
World Trade Organization (WTO), the World Bank
(PRSPs) or other funding institutions.
!
•
I
Step I continued
National constitution, laws and
policy goals.
•
Does the constitution or any relevant law commit the
government to provide health services for the
population?
International Covenant on Economic, Social and
•
Are
there any specific constitutional or legal provisions
Cultural Rights (ICESCR) Article 12: "The state
applicable against which one can assess the right to
parties to the present covenant recognize the right of
everyone to the enjoyment of the highest attainable
health and health care?
standard of physical and mental health"
• Do official documents recognize the basic concept of
ICESCR General Comment 14 specifies the
comprehensive and universal primary health care? Are
desirability of a national legislation on Right to health:
they in any way committed to "Health for All"? Do they
"56 States should consider adopting a framework law
refer to the Alma Ata Declaration of 1978?
to operationalise their Right to Health in their national
strategy. The framework law should establish national
• Are there specific commitments related to women’s health ,
mechanisms for monitoring the implementation of
and nondiscrimination concerning women? Commitments ‘!
national health strategies and plans of action."
related to children’s health? To other vulnerable groups
such as disabled people, people living with AIDS,
GC 14 also stipulates. "The obligation to fulfil requires
State parties, inter alia, to give sufficient recognition to
refugees, migrants, adolescents, ethnic minorities, male
the Right to Health in the national political and legal
and female sex workers, incarcerated men and women,
systems,
preferably by
way of legislative
and mentally ill people?
implementation", "...and to adopt a national health
policy with a detailed plan for realizing the Right to
• Do official documents speak of the need for the
Health".
availability of essential drugs and the need of price
controls for drugs?
"States must ensure provision of health care...
including immunization programmes against the major •
Do policies place targets regarding public health
infectious diseases, and ensure equal access for all to
investment as percentage of the GDP? 8
the underlying determinants of health, such as
nutritiously safe food and potable drinking water, basic
• Do policies mandate equitable distribution of resources to
sanitation and adequate housing and living
all segments of the population (e.g., urban-rural, different
conditions."
geographical areas, different ethnic groups)?
"Public health infrastructures should provide for sexual
and reproductive health services, including safe
motherhood, particularly in rural areas.
Step 1 Conclusion
Summarise your government’s current obligations regarding the Right to Health and Health
Care.
I
I
B For example:
.
Countries to raise the level of tax revenue to at least 20% of their GDP.
.
Public health expenditure (including government and donor financing) to be at least 5 /o of the
*
.
Government expenditures on health to be at least 15% of total government expenditures:
to be at least 50% ofp-chealth
:
.
ZXXXIX1 «“) to be at tast 40% ottotal pubHc and private
..
Z expenditures on district health services in the highest spending district over that ot the lowest spending district to
■ Zi'“ «
I
^"oo "nce of
STEP II. Are your government's policies appropriate to fulfill
these obligations?
!
In addition to what is explained in Section 2 under this step, consider answering the following
MAIN AREAS TO
ASSESS
Which are the main policies
and programmes that guide
the health system in your
country?
'!
RELEVANT ISSUES TO EXPLORE
Checklist:
• Five-year national health policy or plan,
• Reproductive health policy and/or family planning policy,
• Women's health policy,
• Policies targeting AIDS, tuberculosis, mental health or other
conditions,
• Drug policy including (or not) essential medicines price controls,
• Programmes to provide health care to the poor,
• Other.
Pay specific attention to what policies and programmes say regarding:
• Primary health care;
_
i ji
• Services to remote areas;
• Village health workers;
• Decentralization;
• Privatization.
I
I
I
I
What external factors have influenced these policies (e.g., debt, war,
the impact of HIV/AIDs, other)?
Are there any programs that already prioritize vulnerable groups for
services? What are these groups and in what way are they targeted?
<*8!
I
Step II continued
Who participates or
participated in the
development and
implementation of health
policies and programmes?
What are the perceptions of affected groups regarding their major
health problems and how they relate to the main national health
policies? Have they received adequate information?
[Rather than just talking about people, it is a good idea to talk witL
them and find out their views].
Checklist of participation:
• village/community committees,
•
voting in elections and referenda (local, regional and national),
•
patients' associations and volunteer organizations,
•
•
government-NGO partnerships,
any consultation in the development, monitoring and evaluation
•
stages of policy,
representative committees that monitor the implementation of
•
services,
oral and written reports to international organizations and to
national and international conferences.
government advisory bodies
•
Where can people go to make a complaint (mechanisms for redress)?
Are these mechanisms being used? Do these mechanisms
effectively redress problems?
What are the main changes
taking place in your health
system that concern you as
public health-oriented
advocates?
Checklist of areas of concern:
• Health sector reform (Have ‘reforms' involving reduced public
subsidies or ‘cost-effective measures’ -based on policy
prescriptions by international institutions - been implemented in
•
some form in the country?).
Privatisation (Have any public health services been privatised? If
so, these should be listed and the impact of this privatisation on
•
I
I
access to health services should be documented).
Participation in decision-making (Understood as the involvement
of the beneficiaries in all health-related decision-making, as well
as in the development, implementation and monitoring of policies,
•
•
plans and strategies).
User fees.
The dismantling of primary health care programmes.
•
•
•
National vertical programmes
Population control and Family Planning.
Women s health and reproductive health policies.
•
Pharmaceutical and drug policies.
•
Other.
MlI
Step II continued
What is the budget allocated
What is the government expenditure on health as percentage of GDP9
to health? How is health
What is the overall (public and private) per capita spending on health
care financed?
care? (See footnote 9)
A change in the health budget
caused by a shift in allocations within
the total national budget indicates a
change in priority. A decrease in the
total budget makes it more difficult to
improve health rights. However, it
does not relieve the government of
its responsibility to at least protect
‘vulnerable’ members of society.
What is the percentage of government spending as a proportion of the
total expenditure on health care? Has this percentage been falling? Does
the health care system function to transfer money from taxpayers and
patients to private enterprises?
What is the government pei capita spending in rural areas compared to
urban areas? (In 2000, the World Health Organization estimated that $60
per person per year was needed for reasonable health care.)
How does the above compare with other countries with the same level of
development?
Is the budget for health decreasing or increasing, i.e., has government
spending in the health sector diminished in relative or absolute terms? If
so, can you quantify the cuts made in the budget?
As a result, do fixed expenditures (especially salaries) now tend to take
up a larger part of total expenditures? Can you quantify this in
percentage?
Which areas have been most affected by budget cutbacks or by increased
investments, e.g. infrastructure, salaries, medical supplies, rural health
services, secondary & tertiary health care?
I
Are expenditure patterns on health care skewed in favour of urban areas?
Have investments correspondingly fallen in rural health services?
Are there significant public-private inequalities in health expenditure and
coverage?
What kind of health staff is
available? Is it sufficient?
A functioning health system requires sufficient staff that is well trained,
gender sensitive and motivated.
Checklist of staffing issues:
•
Ratio of doctors to population in rural areas compared to urban,'
ICESCR, GC f4:“States have to
ensure the appropriate training of
•
doctors and other medical
•
personnel, the provision of a
sufficient number of hospitals, clinics
•
and other health-related facilities,
and...the establishment of
institutions providing counselling and •
mental health services, with due
regard to equitable distribution
•
throughout the country."
•
I
Availability of staff in different regions (particularly minority areas),
Representation of different ethnic, religious and cultural, groups
among staff.
Balance between female and male staff, especially in decision-making
positions,
,
Number and quality of staff available for special sectors of the health
system, e.g., the private sector or foreign-funded programmes,
Emigration of health staff,
Is the training of health staff adequate for the needs of the country?
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^3
Step II continued
Have public health services
been privatized?
Have health programmes suffered dufe to reduced funding or
privatization? If so, this change should be quantified to the extent
possible.
Are health services sub-contracted to profit making companies or to
NGO’s? What are the largest for-profit health-related corporations in
your country?
i
Does the government provide incentives, tax holidays and subsidies
to the private sector (including the private pharmaceutical and the
medical equipment industry)?
More about this is found in step III.
To what extent do other
international actors expand
or limit the capacity of the
government to implement
health programmes?
What are the priorities of those other actors? (Donor countries are
usually more willing to fund activities that correspond to their
priorities).
Checklist international actors:
• other governments,
• international donors
i|
• International agencies such as the World Bank, IMF, WTO, UNDP,
:
EU, WHO'. ILO, UNICEF, UNFPA,
• transnational and multinational corporations.
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Look at the positive and negative influences of technical and financial
assistance on the right to health and health care.
Step II Conclusion:
Summarise the appropriateness or inappropriateness of the government’s health sector
policies and programmes in relation to the right to health and health care.
!
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Step III. Is the health system of your country adequately
implementing interventions to realize the right to health and
health care for all?
In addition to what is said in Section 2 under this step, consider answering the following:
MAIN AREAS TO ASSESS
RELEVANT ISSUES TO EXPLORE
What is the situation regarding the
availability of relevant health
services, goods and facilities?
What does the government do to
insure availability?
What are the trends in availability,
especially for marginalized
groups?
Checklist of indicators of availability:
• Services are functioning,
• They are available in sufficient quantity throughout the
country,
’ ‘
ICESCR General Comment 14, paragraph
12: “Functioning public health and health
care facilities, goods and services, as well as
programmes, must be available in sufficient
quantity in the country.
•
The inputs needed for adequate functioning exist at
health care delivery points (water, sanitation, buildings,
personnel, drugs, workplace environment),
•
The availability of appropriate mental health and HIV
and AIDS treatment and care,
•
The availability of emergency medical'care for
accidents and disasters,
Programmes that discourage the use of alcohol,
tobacco, drugs and other harmful substances.
•
Checklist of vulnerable or marginalized groups:
Girls, adolescent and older women;
Refugees, internally displaced people and migrants;
Ethnic minorities and indigenous populations;
Sex workers;
People with physical or mental disabilities;
People living with HIV/AIDS;
Incarcerated men and women.
Other, as relevant in your country.
What does the government do to
guarantee the quality of services?
Checklist of indicators of quality:
•
li ICESCR General Comment 14, paragraph
12d: “Health facilities, goods and services
must be scientifically, as well as medically
appropriate and of good quality This
requires, among other, skilled medical
personnel, approved and unexpired drugs
and hospital equipment, safe and potable
water and adequate sanitation".
•
•
•
Government licenture or certification of health
personnel requires demonstration of minimum.skills
consistent with international standards,
The drugs, equipment, buildings and sanitation in health
facilities are scientifically and medically appropriate,
The government promotes international standards of
care for mental health and HIV/AIDS services,
Measures are taken to discourage irrational use of drugs
and of inappropriate technologies.
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Step III continued
What does the government do to
guarantee access to health care
services, goods and facilities? What
have been the trends in this respect?
ICESCR General Comment 14, paragraph
12b: “Health facilities, goods and services
must be accessible to everyone without
discrimination, within the jurisdiction of the
State party"
Vulnerable and marginalized groups are particularly
I*
important to consider.
ii
Access includes physical access, economic access
(affordability) and information access.
Checklist of indicators of physical access:
• Existence of services at community level (distance or
travel time to services),
• Access to buildings for persons with disabilities,
• A safe and supportive environment for youth,
. Barriers which the poor face to access health facilities
such as high fees for services, absence of convenient
and affordable public transport,
• Opening hours.
Checklist of indicators of economic access:
• Average percentage of household income spent on
health,
. Proportion of household income spent on health by the
poorest 25% of the population (or any other indicator of
equity of access),
• Free services (where called-for) for safe pregnancy,
childbirth and post-partum care,
• Sufficient funds are available to run health care facilities,
• Health insurance and health care for the poor,
• Prices of drugs: Have there been substantial increases?
Does the government subsidize them?
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Has privatization affected the
availability and access of health
services for the poor and
marginalized groups?
Legal precedents
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See the checklist on vulnerable and marginalised groups
above. Consider mechanisms to regulate the actions of the
private sector, the application of user fees, economic barriers
to hospitalization.
Have there been any court cases concerning the right to
health and health care, i.e., where your government or other
actors have been taken to court over health issues?
Document these cases.
Step III continued
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What does the government do to
guarantee the acceptability of
health care services, goods and
facilities?
CEDAW General Recommendation 24, paragraphs 12
and 22:12. States parties should report on their
understanding of how policies and measures on health
care address the health rights of women from the
perspective of women's needs and interests and how it
addresses distinctive features and factors which differ
for women in comparison to men, such as:
(a) Biological factors which differ for women in
comparison with men;
(b) Socio-economic factors that vary for women in
general and some groups of women in particular. For
example, for women and men in the home and
workplace, for different forms of violence for the girll
child and adolescent girl Some cultural or traditional
practices such as female genital mutilation also carry a
high risk of death and disability;
(c) Psychosocial factors which vary between women and
men including depression, as well as conditions that
lead to eating disorders;
| (d) Lack of confidentiality affects women detering them
from seeking treatment. Women are less willing to seek
medical care for diseases of the genital tract, for
contraception, for incomplete abortion and in cases
: where they have suffered sexual or physical violence
Do the services and goods correspond to users' needs and
expectations?
Checklist of indicators of acceptability
•
Respect for patients’ dignity,
•
Respect for confidentiality,
•
Sensitivity to women’s and minorities’ special needs and
perspectives,
•
Respect for the culture of minorities and communities.
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t
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22. States parties should also report on measures taken
to making health care more acceptable to women, e.g.,
seeking their informed consent, respecting their dignity
and, guaranteeing confidentiality. States parties should
not permit forms of coercion, such as non-consensual
sterilization, mandatory testing for sexually transmitted
diseases or mandatory pregnancy testing as a condition
i of employment.
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Step III Conclusion
Summarise the adequacy of the current health delivery system to achieve the right to health
and health care.
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Step IV. Does the health status of different social groups and
the population as a whole reflect a progression in their right to
health and health care?
In addition to what is said in Section 2 under this step, consider answering the following:
RELEVANT ISSUES TO EXPLORE
MAIN AREAS TO ASSESS
General health indicators
What is the government doing to
remove barriers to the enjoyment
of health rights of the poor,
minorities, and marginalized
groups?
•
.
Life expectancy by income quintile,
Main causes of death for adults, disaggregated for women
and men, rural and urban areas
•
•
Measures taken to meet their specific health needs,
Participation of the groups concerned in decision
.
.
•
-
Health status of women
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CRC Article 24, 2: (State Parties shall.take
appropriate measures "(d) To ensure
appropriate pre-natal and post-natal health
care for mothers."
“(f) To
develop preventive health care, guidance
for parents and family planning education
and services."
•
•
•
.
•
.
making,
Measures taken to reduce the stigma of HIV/ AIDS,
mental illness and and other medical conditions,
Measures taken to reduce marginalization of women
heads of household, minority groups and the poor.
Examples of instances in which the right to health and
health care was realized?
Differences in under 5 mortality rates between girls and
boys,
Maternal mortality rates,
Percentage of women that die in childbirth,
Percentage of births attended by medically trained
personnel in rural areas,
Trends of these in the last 5-10 years,
Are family planning policies aiming at giving women
informed choice or only at controlling population growth?
a
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Step IV continued
Health status of children
•
2i: “1' States Parties rec°9nize the right
of the child to the enjoyment of the highest attainable
standard of health and to facilities for the treatment of
illness and rehabilitation of health. States Parties shall
stnve to ensure that no child is deprived of his or her
right of access to such health care services."
tk'
Parties shal1 Pursue full implementation of
meaTures^'ln particular’ shal1 take appropriate
•
•
•
•
Infant mortality rates, disaggregated by sex and
rural/urban areas,
How many avoidable/preventable child deaths per day?
Which are the major killers?
Immunization coverage rates,
Trends of these in the last 5-10 years.
i
“(a) To diminish infant and child mortality."
(b) To ensure the provision of necessary medical
assistance and health care to all children with
emphasis on the development of primary health care."
C!J°£Onlbat d'sease and malnutrition, including
within the framework of primary health care, through
inter aha, the application of readily available technology
and through the provision of adequate nutritious foods
and clean drinking-water, taking into consideration the
dangers and risks of environmental pollution "
oarenN
a" se9.ments of society- particular
parents and children, are informed, have access to
education and are supported in the use of basic
kno w/edge of child health and nutrition, the advantages
of breastfeeding, hygiene and environmental sanitation
and the prevention of accidents."
Considering the above, is the
current health system
discriminatory?
A policy violates the right to non-discrimination if it:
negatively affects some groups, but not others;
•
•
positively affects groups that were already
advantaged (thereby widening the gap);
affects all groups equally, without taking into
groups1 S,'9nificant differences between those
reaffirms stereotypes, which maintain certain
groups in an inferior position.
A policy is considered not discriminatory if it has a
positive effect on only disadvantaged groups- on the
! qhpp f °n-that?18 3 temPorarV special measure with the
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If yes, on which basis are people discriminated against?
Checklist of grounds for discrimination:
• sex and gender,
age,
race and ethnicity.
health status/disability,
sexual orientation,
language,
religion,
political or other viewpoint,
income,
national or social origin.
and
reCLUCIn9 the99ap between advantaged
and disadvantaged groups.9
a
Step IV Conclusion
X(ne9a,iVe °r P0S"iVe) °f ,he hMl,h care
9
- ----- --
HeRWAI, 2006, page 38
system in your
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Step V. What does the denial or fulfillment of the Right to
Health in your country mean in practice?
Here you will be looking at the fulfilment of relevant State obligations The most relevant core
obligations for the Right to Health are listed and defined below. A detailed explanation of the
concepts of core obligations can be found in ANNEX II. You are asked to select the obligations
which are most relevant to the present situation, and to explore the difference between what
your government has promised to do (Step II) and what the government has actually achieved
(Step IV). This difference provides strong arguments to improve the right to health and health
care situation, and will help you to determine the violations for which you can hold your
government accountable. Be aware that quantity is not a factor in determining if a violation has
occurred. If discrimination takes place, it is a violation of human rights, regardless of the
number of people who are discriminated against.
RELEVANT ISSUES TO EXPLORE
MAIN AREAS TO ASSESS
Core obligations require your government to ensure, at the
Which of the core obligations are
not being fulfilled?
very least, minimum essential levels of:
• Access to health facilities, goods, and services on a nondiscriminatory basis, especially for vulnerable or
ICESCR General Comment 14 specifies certain Core
obligations of States related to the Right to Health:
43. "States parties have a core obligation to ensure the
satisfaction of, at the very least, minimum essential
levels of each of the rights enunciated in the Covenant,
including essential primary health care."
"(a) To ensure the right of access to health facilities,
goods and services on a non-discriminatory basis,
especially for vulnerable or marginalized groups;"
"(d) To provide essential drugs, as from time to time
defined under the WHO Action Programme on Essential
Drugs;"
"(e) To ensure equitable distribution of all health facilities,
goods and services;"
“(f) To adopt and implement a national public health
strategy and plan of action, on the basis of
epidemiological evidence, addressing the health
concerns of the whole population; the strategy and plan
of action shall be devised, and periodically reviewed, on
the basis of a participatory and transparent process; they
shall include methods, such as Right to Health indicators
and benchmarks, l?y which progress can be closely
monitored; the process by which the strategy and plan of
action are devised, as well as their content, shall give
particular attention to all vulnerable or marginalized
groups"
j
marginalized groups,
•
•
Access to food,
Access to shelter, housing, water and sanitation,
•
Access to essential drugs.
The following core obligations are of comparable priority:
•
Reproductive, maternal (pre-natal, as well as post-natal)
•
and child health care;
Immunisation against major infectious diseases;
•
Measures to prevent, treat and control epidemic and
•
endemic diseases;
Education and access to information concerning health;
•
Training for health personnel, including education on health
•
and human rights.
Equitable distribution of all health facilities, goods and
•
services:
A national public health strategy and plan of action.
Are these ensured?
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Step V continued
Is the government moving forwards
towards a universal right to health
and health care?
The obligation of progressive realization requires
governments to do whatever they can to improve the health of
The Universal Declaration of Human
their people. This means that if the government £an achieve
Rights, Article 25: "Everyone has the right to
more, it has the obligation to do so.
a standard of living adequate for... health
and well-being of himself and his family
Can it? Is it?
including food, clothing, housing, medical
care and the right to security in the event of
... sickness, disability... Motherhood and
childhood are entitled to special care and
assistance...”
Or, is the government failing to
maintain its achievements
regarding health rights?
The obligation of non-retrogression is applicable only if:
• the deterioration is avoidable,
• the government has not doQe all it can to prevent the
deterioration,
• the government has not asked for international assistance
to address the problem, and/ or
‘f
• the government has not protected vulnerable groups
against the deterioration.
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Which of the violations you found
are a result of the government’s
failure to meet its obligations to
respect, protect and fulfil health
rights?
| ICESCR GC 14: "52. Violations of the
obligation to fulfill occur through the failure of
States parties to take all necessary Steps to
ensure the realization of the Right to Health.
Examples include the failure to adopt or
implement a national health policy designed t
o ensure the Right to Health for everyone;
insufficient expenditure or misallocation of
public resources which results in the non
enjoyment of the Right to Health by
individuals or groups, particularly the
vulnerable or marginalized; the failure to
monitor the realization of the Right to Health
at the national level, for example by
identifying Right to Health indicators and
benchmarks; the failure to take measures to
reduce the inequitable distribution of health
facilities, goods and services; the failure to
adopt a gender-sensitive approach to health;
and the failure to reduce infant and maternal
mortality rates."
I
The government fails to respect people’s health rights if its
policies reduce people’s chances to enjoy good health.
The government fails to protect people’s health rights if its
policies permit others to endanger people’s health.
The obligation to fulfil means that the government has to take
positive measures that enable and assist people to enjoy their
health rights.
It is a good idea here to refer to the commitments you identified
in Step II.
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Step V continued
Which of its commitments is the
government more specifically
violating?
Who are the responsible duty
bearers for each major violation?
Refer to all commitments identified in Step I to respond to this
question.
Which government agencies or departments are responsible
for the denial or violations of people’s health rights? Which
individuals in the government? Which other national actor(sP
Do foreign governments or international actors have an
influence on the violations?
■
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Is lack of resources a major
obstacle?
If yes:
•
•
•
•
Has the government used the resources it does have to
the maximum extent?
Has the government attempted to obtain international
technical and financial assistance?
Have other (donor) governments or international institutions
extended the necessary assistance?
Document any examples of efforts to take steps that did not
require additional resources.
Base your answer on your findings in Step III.
Step V Conclusion
Summarise the denials/violations for which you can hold your government accountable.
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4. What needs to be done to challenge the key
elements of the denial of the Right to Health in your
country?
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In today’s world the technical means exist to provide basic health-related services for all
people. Even some developing countries with comparatively low per capita incomes have
achieved significant progress towards securing the right to health and health care for all their
citizens.
However, a range of political and economic factors, policy decisions, and gaps in
implementation, lead to some denial of health rights in every country. In the final step of this
guide you will compile the information you have gathered the form of recommendations to
improve government health policy. You will then use these recommendations or demands to
prepare your national action plan to realise the right to health and health care. Further on in the
PHM campaign, all the countries which have gone through this process will meet to share their
findings and plans, and decide on what international steps can and should be taken to support
their common goals.
We suggest that the policy recommendations and action plan be developed in a participatory
process that includes people who are usually left out of policy discussions. You will present the
cases of violations of the right to health and health care you documented with this assessment
tool. Participants will decide what changes should be made to stop these violations, and what
should be done to bring about those changes. It is expected that each country will have
different policy ideas and activist strategies that come out of that particular country context.
The final product of your work will include a summary of the findings of the assessment, the
policy and action recommendations, and at least a draft action plan. As we share this work
internationally, common problems and solutions will emerge. We will build a groundswell of
understanding of and support for human rights as the basis for development. Backed by all
those who have contributed to the RTHHC, PHM will then take those common demands to the
pertinent international institutions.
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4.1.Developing your policy recommendations
Having carried out this assessment, you have clearly identified human rights gaps in the area
of health care in your country, and you have documented them with qualitative and quantitative
data. Use the following questions to help you decide which violations you will prioritize in the
recommendations or demands.
and h0U|th°nfiCirepeated an^-cont'nued vio|ations of the right to health
Which of the violations you document are of major concern in your country at this time?
Can several of the specific violations you have documented be addressed by chanqes in
one policy area?
Do beneficiaries and NGOs you have worked with on the
the assessment
assessment share
share your
your findings?
findings?
Are they willing to start mobilising to challenge relevant duty bearers?
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For each of the violations you have identified in Step V, try to formulate a recommendation to
bring the government into compliance with its health rights obligations. Consider the following
in formulating the recommendations:
•
•
•
•
•
•
•
Policy stage: The stage the respective policy is in may determine the type of solution or
recommendation to be made and whom you need to approach.
Objectivity: Try to be as realistic as possible. In many cases, no easy solution will be
available. This does not release the government from its obligations. The recommendation
you may choose might be to undertake further research into the causes of and possible
solutions to a specific health problem identified.
Type and basis of your arguments: Depending on who needs to be convinced, it may be
strategic to use more legal, more medical or more political arguments.
Groups affected: Try to find solutions that suit the groups most affected by the policy (or
absence of it). It is best to involve the most affected groups in the development of your
recommendations.
Ownership: Whenever possible, you should involve the responsible policy-makers/duty
bearers in the search for alternatives. This will increase their ownership of the suggestions
and their chances for acceptance.
Preparedness: In Step V, you identified the main obstacles to the government meeting its
obligations. The government will probably refer to those obstacles when confronted with
your findings. What will your counter-arguments be? Build your case in advance of such a
dialogue.
Include benchmarks: Benchmarks make it easier to monitor achievements. For each of
your recommendations try to set benchmarks that will measure the impact of the policy
changes. Preferably, these benchmarks should be related to those already set by the
government, or proposed by WHO or other respected organization. If you are not able to
formulate them yourself, you can also insist the government achieves its own benchmarks,
adjusts them or sets new ones as needed.
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If policy change is not the solution, what action should the government take? Be prepared to
make such recommendations. Consider things such as: scrapping bad policies; setting up a
compensation mechanism for affected groups; or the publication of regulations to control the
actions of, for example, the private sector.
4.2. Questions to answer in preparing your action plan
To which government department or person should you direct your lobbying efforts?
To increase the chances that your recommendations are implemented, it is important to
consider whom you are presenting the information to. The governmental level, role and
competencies of the department or person will determine if they are able to actually make the
changes you are demanding. Do they need authorization from a higher level? Have certain
government responsibilities been delegated to the municipal or regional level? Should you aim
your lobbying at those developing the policy or at those implementing or evaluating the
policy? Are there procedures you must follow to get the attention of a particular department?
Some governments or policy-makers are not aware of their human rights obligations. You
may need to explain to them what their obligations are in relation to the Right to Health.
Which other governments, funding agencies or other actors should you approach to
point out how their funding or actions should contribute to the the realization of the
right to health and health care in your coutry?
I
These other actors may be able to put external pressure on governments or on private actors
and may have an influence on the situation itself. When aiming your lobbying at Wiese other
actors keep in mind what their exact role/ mandate is and what they are most sensitive to.
What is the most strategic time to present your findings?
The response to this question requires some knowledge of the government’s agenda or the
agenda of other actors you may want to approach. What deadlines are involved in changing a
given policy? A conference, a debate in parliament, a visit of a high-level official, etc. can all
provide strategic entry points to present your findings. It may also help to coordinate your
actions with the international level of the right to health and health care Campaign.
What options are available to you to increase pressure on the government?
It is a good idea to identify other things you can do, besides lobbying, to pressure the
government, for example public interest litigation (i.e., suing the government for the violation
of human rights), going public using the local press, or mobilizing the affected community(ies)
for mass actions. Begin thinking about how the global PHM can support and endorse your
demands.
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When and how will you check whether changes have really led to an improvement of the
right to health and health care?
This check is necessary, because even if the government accepts your recommendations, this
does not mean that the desired results will be achieved. It is possible that the changes you
suggested were not adequate to improve health rights, or that other factors hampered their
successful implementation. Use the benchmarks you defined earlier to set up a monitoring
plan in advance.
What awareness-raising activities should you use to inform the public about your
findings and recommendations?
Lobbying the government should be accompanied by advocacy work, to make people aware
of their health rights and how they are being violated. This can be done through the media,
organizing a conference or workshop, producing and distributing a leaflet or video, etc.
Disseminating your findings to other organizations with an interest in health rights is a good
strategy to involve more people in the right to health and health care Campaign.
How much time and which resources (financial and in terms of skills) does your
organization need to implement your action plan? Can these resources be made
available?
Developing a time frame and a budget will help to make a realistic action plan and will be
useful if you need to ask for outside assistance and funding. If you do not have experience with
lobbying, share your findings with more experienced organizations and invite them to get
involved in the Campaign.
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5. Concluding remarks and contact information
Always keep, in mind that this exercise on which you are embarking is part of a global effort to
reverse the violations of the right to health and health care both in rich and poor countries.
We again recommend that you review the campaign proposal as posted at the PHM website
(W.w.phmQyement.org.) under ‘Right to Health’. This will help you understand the
campaign in its entirety and to keep things in perspective,
yoip can seek further advice from others in the People’s Health Movement.
At any time, yoijj
• The PHM website: www.Dhmovement.org
• The PHM Global Secretariat: secretariat@phmovement.org
• The PHA Exchange listserve: pha-exchange@lists.kabissa.org
• The Right to Health and Health Care Campaign core group members are available to
support you. We also welcome your feedback:
Saskia Bakker (Netherlands), s.baskker@hom.nl
Ariel Frisancho (Peru), afrisanchoarroyo@yahoo.es
Abhay Shukla (India,) abhayseema@vsnl.com
Cristianne Rocha (Brazil), cristianne.rocha@terra.com.br
Claudio Schuftan (Vietnam), claudio@hcmc.netnam.vn
Laura Turiano (USA), phm@turiano.org
[The names and email addresses of regional coordinators will be added at a later stage].
When you complete your assessment, we ask you to send a copy of your summary results and
tentative action plans to the campaign core group at PHM: phm@turiano.org
Congratulations on your work with the right to health and health care Campaign. You
will hear from the core group when we are ready to launch phase II of the campaign.
■f
Annex I. CONCEPTS AND DEFINITIONS
What is the right to health and health care?
The right to health includes the availability, access, acceptability and quality of health1 care. Health is a
fundamental right that influences all aspects of life, so it is important to look at health.in a broad way. It
is closely related to other human rights. Although we focus our analysis on the right to health, this does
not mean it is considered more important than others are.
1
What is the principle of non-discrimination?
The principle of non-discrimination is a cornerstone of human rights. It means that all people have the
same human rights even if they are different in some way from others. For example, discrimination
based on sex is one common type of discrimination.10 Women and men should have equal access to
health care. However, non-discrimination does not mean treating everyone the same. Such an
approach disadvantages women as a result of past discrimination. Women require different treatment
from men due to biological factors, socio-economic factors, and psychosocial factors.11
States have important obligations with regard to discrimination:
■
■
■
■
to eliminate not only their own discriminatory practices, but also those of individuals.
to address direct as well as indirect discrimination. An example of an indirect discriminatory law is
one that requires everyone to pay the same amount for health care, even though the cost is
unaffordable for people without paid work, such as elderly widows.
to implement temporary special measures (where necessary) to reverse the .effects of past
discrimination on particular groups.
to take measures to ensure that women and men can, and do, participate in society on
an equal basis, such as removing barriers which women face access their rights.
What is the principle of participation?
The participation of the general population in all health-related decision-making at the community,
national and international levels is an important aspect of the right to health. Individuals and groups
should be involved in making decisions about health policies.12 They should also have an opportunity to
make complaints about the negative effects of laws and policies. Because of traditional gender roles,
women tend to participate less than men in political and public life.13 Involving women in decision
making therefore requires specific attention by the government.
10
Universal Declaration of Human Rights, article 2; CEDAW article 1 and 2: ICE SCR Articles 2 and 3, General Comment 16
CEDAW article 1, ICESCR general comment 24, paragraph 12
12
ICESCR general comment 14, paragraph 54. see also paragraph 11 and 17
13
CEDAW general recommendation 19, paragraph 11
11
I
What is policy?
A policy is a plan of action. A policy can refer to a nationwide five-year health strategy or to decisions
about a particular disease or region. The process by which policies are developed can involve local or
national government, NGOs, or individuals. This assessment mostly concentrates on government
policy. The government policy process follows a number of stages (at least in theory):
■
■
■
■
■
Agenda-setting: the process by which problems come to the attention of government;
Policy formulation: the process by which policy options are identified by government;
Decision-making: the process by which the government adopts a certain course of action (or non
action);
Policy implementation: the process by which the government puts the policy into effect;
Policy evaluation: the process by which the results of policies are monitored both by the
government and by civil society and which may lead to a new set of stages.
During the stages of agenda setting, policy formulation and evaluation, people's
organizations may have a particularly strong role. In other stages participation may be
more difficult.
What are health reforms, PRSPs, MDGs and how do they influence health
policies?
Many countries throughout the world have introduced health sector reforms to control the costs of
health services. These reforms have serious implications for the right to health.
A much-debated trend is the privatization of health related services, whereby the government allows
and often stimulates the private sector to take over the provision of certain services (e.g., in health
clinics) or goods (e.g., the distribution of contraceptives). In some countries, health sector reforms are
the result of Poverty Reduction Strategy Plans (PRSP), which governments write to be eligible for
loans from the IMF, the World Bank and other donors. PRSPs determine the direction of health policies
and their budgets.
The Millennium Development Goals (MDGs) also have a considerable influence on health rights. This
influence may be positive because the MDGs prompt governments to take action on many health
related issues. But the MDGs may also have a negative effect if attention and resources are drawn
away from important areas. For example, sexual and reproductive rights do not have a prominent place
in the MDGs and may not receive necessary funding.
Similar discussions are taking place concerning the effects of the General Agreement on Trade in
Services (GATS) and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)
on the price of health services and drugs.
This right to health and health care assessment can show how these agreements impact the health
rights of certain groups. In addition, the progress reports that countries make for the PRSPs, the MDGs,
etc. may provide useful information for our analysis.
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9
How does globalization effect a government's responsibility for the right
to health and health care?
Governments’ first responsibility regarding the right to health is at the national level. But in a globalized
world, governments have a growing responsibility at the international level. First of all, a country’s
actions often have impacts beyond its national borders. Air and water pollution are clear examples of
such influence. Secondly, governments help each other on a bilateral basis, such as through
development cooperation. According to human rights treaties, governments have the obligation to
support each other in implementing health rights. A third way in which governments have international
influence is through multilateral institutions. Influential international institutions such as the World Bank
are owned by the governments of member nations, which have ultimate decision-making power within
the organization. Last but not least, governments monitor each other through international agreements.
These may be bilateral or multilateral; legally binding, such as UN human rights treaties, or morally
binding, such as the Millennium Development Goals. It is clear that in a globalized world, decisions at
the local, national and international levels influence each other.
I
Annex II WHAT ARE HUMAN RIGHTS?
Human rights are the rights possessed by all persons, by virtue of their common humanity. The first
and most influential document describing human rights is the Universal Declaration of Human Rights
of 1948. It is the predecessor of the major human rights treaties. The declaration recognizes the
inherent dignity and equality of all human beings, the notion that lies at the heart of all human rights
Some other features of human rights are listed below:
• Human rights are fundamental, because individuals need them to survive, to develop and to
contribute to society. They are the primary means for every person to develop their full potential.
• Human rights are not granted by governments or by international law. Every individual has human
rights and is entitled to all of his or her human rights by virtue of being human.
• Human rights are inalienable. They cannot be taken away from a person or denied to a person bv
the State.
7
•
•
Human rights are universal. This means that every human being is entitled to human rights,
regardless of gender, race, age, ethnicity, citizenship, religion, disability or other status.
Human rights are indivisible; they are closely connected. The realization of the right to health, for
example, is closely connected to the realization of other human rights, such as the right to
education, food and an adequate standard of living.
Women’s rights are human rights
Even though all general human rights treaties include a provision on the equality of men and women,
this has not proven sufficient to eliminate discrimination against women. The Convention on the
Elimination of all forms of Discrimination Against Women (CEDAW) was developed to focus on the
elimination of discrimination of women in a broad sense. By adopting this treaty in 1979, States
recognized that special attention was needed to women’s human rights. CEDAW clearly defines what
discrimination against women means and what States should do to prevent it. 25 years after its
adoption there is still a gap between respect for women’s rights on paper and in practice: CEDAW
provides a good basis to claim justice and equality for women throughout the world.
Why a human-rights approach?
Human rights treaties are the foundation of a human-rights based approach. States have the
obligation to respect, protect and fulfill the human rights laid down in the treaties they have signed
and ratified. Using the example of poor people’s right to health and health care, this means that
governments are not allowed to violate their health rights (the obligation to respect) and that they
should restrain others - companies for example - from violating them (obligation to protect). Moreover,
the government should do all it can to make sure that poor people achieve the highest attainable
standard of health (obligation to fulfill). In other words, when speaking of human rights we do not speak
of mere aspirations by States, or of the needs of those claiming their rights, but of obligations for
governments. Keeping this in mind, it can be said that:
•
•
A human rights based approach is based on the idea that every human being has rights. States are
responsibly for the realization of these. Citizens can hold the State accountable for its obligations to
respect, protect and fulfill human rights.
The basis of a human-rights approach is that a human rights violation needs to be addressed, even
when the number of people involved is small or not precisely known. In other words, each human
rights violation stands on alone and should be taken seriously. A decrease in numbers of a certain
type of human rights violation is a positive development, but does not excuse other violations still
taking place.
Too
‘
pe°p'e’s hea"h care n,eans mon"°'in9 ,he way ,hey enioy- e*erase ”d
Why use international human rights treaties?
A human rights treaty (or covenant or convention) is a written document binding States under
h ouah rah iraWt
C°UntrieS
39t0 be b°Und by international hUr^an rights treaties
he na9Jon^Xer"
aCCeSS'On
' 16931 Ob'i9ati°n ‘0 imP'ement theSe ri9hts and PrinciP|es
Human rights treaties lay down important principles. CEDAW, for example, states that women and men
must have equal rights with regard to health care and - at the same time -1 that gove^^
boXs^m StPe?h'C h6fth needS °f W°men- Committees of independent experts (treaty-monitoring
treaty XTstates have ^rnrtaftlOn 7
They StUdy rep°rtS °n the implementation of the
proces v ^so calted s^adoX
S
PHM CirC'eS Can Pr°Vide imPortant inPut to this
compla nt
tmatv m ?
the P°SSibility for individuals to subm't
Z
r a treaty-momtonng body. Annex III on Sources and Resources provides links to the
most
relevant international and regional treaties.
i
‘!
i
14 -
.....................■' resol‘J«°"s. which' entai/a moraTbutnot "legal "duty SeXXT d°CUmen,S °f WOr'd confere"^ and the UN
General Assembly
3*1
Annex III. SOURCES AND RESOURCES
I
I
Resources on lobbying and advocacy
Short guide on lobbying. Website of the Education and Training Unit, South Africa.
http://www.etu.org.za/toolbox/docs/organise/weblobby.htm
Short overview of the basics of lobbying. Website of the Democracy Center.
http://www.democracyctr.org/resources/lobbying.html
Online lobbying guide that can be downloaded. Website of the Independent Sector.
.http://www.independentsector.org/programs/gr/lobbyguide.html
Good list of resources for advocacy, focus on ICDP Agenda. Website of the Asia-Pacific
Alliance. http://www.asiapacificalliance.org/SITE_Default/Resources_for_
Advocacy_Default.asp
Good list of general resources on advocacy. Organization focuses on HIV/AIDS.
http://www.aidsmap.com/en/docs/32364953-087A-45D3-AEED-E773BE45593D.asD
General tips on advocacy. Website of the Ugandan AIDS Advocacy network.
Mp://www,phrusa.org/campaigns/aids/uganda/toolkit/eightsteDs_advocacy.DhD
Health indicators, data sources
PAHO gender differences in health and development in 48 countries in the Americas, focusing on
women’s reproductive health, access to key health services and major causes of death.
http://www.paho.org/english/DPM/GPP/GH/GenderBrochure.pdf PAHO Country
Health Profiles. J
httn7/_wv/w,paho.org/english/sha/profiles.htm UNDP Human Development Reports 1990-2005.
http://_hdLunp.org/reports/global/2005/ UNFPA Population and Reproductive Health
Country Profiles.
http://www.unfpa.orq/profile UNFPA State of the World Report 2005.
httP.://www.unfpa.org/swp/2005/english/ch1/index.htm UN Statistics Division.
http://unstats.un.org/unsd/default.htm WHO Health indicators per country.
http://www,who.int/countries/en/ (also available in Spanish and French)
I
WHO World Statistical Information System.
http://www3.who.int/whosis/menu.cfm WORLD BANK
GenderStats; gender statistics and indicators.
http://devdata.worldbank.org/genderstats/home.asp
International treaties
CEDAW Convention on the Elimination of All Forms of Discrimination against Women.
http://www.un.org/womenwatch/daw/cedaw/index CEDAWthe.Optional Protocol.
http://www.un,org/womenwatch/daw/cedaw/protocol/text.htm
CEDAW General Recommendations, (see especially Recommendation 25 on health and 19 on
violence against women)
http://www.un.org/womenwatch/daw/cedaw/recomm.htm
ICESCR International Covenant on Economic, Social and Cultural Rights.
http://www.ohchr.org/english/law/cescr.htm http://66.36.242.93/treaties/cescr.php
ICESCR General Comments, (see especially Comment 14 on health and 16 on equal rights for women
and men)
http://www.ohchr.org/english/bodies/cescr/comments.htm
CERD International Convention on the Elimination of All Forms of Racial Discrimination.
http://www-unhchr.ch/html/menu3/b/d icerd-htm
CRC Convention on the Rights of the Child
CMC C^SJShJS^^
http://www.unhchr.ch/html/menu3/h/m rnwetoc-him
UDHR Universal Declaration of Human Rights.
http://www.unhchr.ch/udhr/
Regional treaties and organizations
African Charter on Human and Peoples’ Rights
http://www1 .umn.edu/humanrts/mstree
—^"ht
the Rights of Women in Africa.
Srorg/horne/Welcome.htm African Cession on Human Rights.
http://www.achpr.org/english/ info/indp^-women en.html
Europe
EU,0PeMpCXXXT/EC^Z European Sod.l Charter (1961).
http://www1 .umn.edu/humanrts/euro/z31eecch.htr n.
I
Council of Europe.
http://www.coe.int/tZe/Hu man Rights/
European Court of Human Rights.
http://www.echr.CQe.int/echr
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I
EU andhttpn/^Kona.euJnt/comm/employment_. social/qender eflusM^ en.html
EU andhttp7feuropa eu.int/comm/health/ph Qverview/0verview_smJ2im
OSCE.
http://www.osce.org/odihr/13371 .html
The Americas
American Convention on Human Rights (1969).
“ Hand
Cultural Rights (1988).
In,erera— o. viote„oe A9„sl
W°me;^
American Commission.
■
r+
http://www.cidh.Qrg/basic.eng.htm Inter-American Court.
http://www.corteidh.or.cr/ihdexjnq.html
3o3
Consensus documents
Beijing plus 5 and Beijing Platform for Action.
ilLtp_;//www,un.org/womenwatch/daw/followup/beiiing+5 htm
Declaration of Alma Ata (1978).
http.7/www.phmovement,org/charter/almaata.html
Declaration of Commitment on HIV/AIDS, ‘Global Crisis-Global Action’ (2001).
http://www.un,orq/qa/aids/coverage/FinalDeclarationHIVAIDS,html
Declaration on the Elimination of Violence against Women (1993).
W.//www.unhchr,<;h/huridocda/huridoGa.n sf/(Symbol)/A.RES.48.104.En?ODendncument
Declaration on the Right to Development (Vienna Declaration and ProgrammT^c^n^ff
http://www.hri.ca/vien-na+5/vdpa.shtml
Declaration bn the Rights of Disabled Persons (1975).
tlttP:/!/www.unhchr.ch/html/menu3/b/72.htm
7'
'
°f"On) ReP0,’ 0*ln,er"a,to"al C°"fere"ca
http://www.iisd.ca/linkaqes/Cairo/program/pOOOOO.html
Maastricht Guidelines on Violations of Economic, Social and Cultural Rights, Maastricht, January 1997
hlip://www1.umn.edu/humanrts/instree/Maastnchtguidelines_.html
Millennium Declaration (MDGs) (2000).
http://www.developmentgoals.org
People’s Charter for Health.
http://www.phmovement.org/pdf/charter/phm-pch-english.pdf
MQQCnl6S f°r the Protectlon of Persons
Mental Illness and the Improvement of Mental Health Care
\ I
V I J.
http://www.unhchr.ch/html/menu3/b/68.htm
. I
Resources on treaties
ABA-CEELI. The CEDAW Assessment Tool: An Assessment Tool Based on the Convention to Eliminate
All Forms of Discrimination against Women.
http://www.riqhtsconsortium.org/re$ources/assessment/CEDAWtool.pdf
Office of the United Nations High Commissioner for Human Rights.
www.ohchr.org/english/law/index.htm
Human Rights Library of the University of Minnesota.
www1.umn.edu/humanrts/treaties.htm
Treaty Body Database on the Implementation of CEDAW and Other UN Human Rights Conventions
www.unhchr.ch/tbs/doc.nsf
Women s Human Rights Net provides information about women’s human rights throughout the world
Also available in French and Spanish.
www.whrnet.org
Other documents of interest
OHCHR, Draft Guidelines: a Human Rights Approach to Poverty Reduction Strategies
2002, CESCR. http://www.unhchr.ch/development/povertyfinal.html
WHO: 25 Questions and Answers on Health and Human Rights, WHO Health and Human Rights
Publication Series, Issue No.1, 2002. http://www.who.int/hhr/activities/publications/en
Special Rapporteur on Violence against Women: Cultural Practices in the Family That Are Violent
towards Women, Report of the Special Rapporteur, January 2002.
www.unhchr.ch/Huridocda/Huridoca.nsf/Q/42e7191fae543562c1256ba7004e963c/$FILE/G0210428.pdf
Annex IV, GLOSSARY
Accession: When a State becomes party to a treaty after it has already been negotiated and signed by
other States (generally when the treaty has already entered into force). It has the same legal effect as
ratification. The conditions under which accession may occur a'nd the procedure involved depend on
the provisions of the treaty.15Also see Ratification.
Advocacy: A process aimed at influencing policy decisions and lawmaking at national and international
levels. Actions designed to draw a community's attention to an issue and to direct policymakers to a
solution.16Advocacy requires the existence of explicit mechanisms for the participation of organizations
of civil society.
Availability requirement: Functioning public health and healthcare facilities, goods and services, and
programs must be available in sufficient quantity within the State party.'7
Access requirement: Health facilities, goods and services must be accessible to everyone without
discrimination, within the jurisdiction of the State party. 18lt is of particular importance to consider the
removal of barriers faced by vulnerable and marginalized groups. Access includes:
• Physical access: facilities within safe physical reach for all sections of the population, especially
vulnerable or marginalized groups.
• Economic access (affordability): affordable for all, including socially disadvantaged groups. For
example, poorer households should not be disproportionately burdened with health expenses as
compared to richer households.
• Information access: the right to seek, receive, and impart information and ideas concerning health
issues. Access of information should not impair the right to have personal health data treated with
confidentiality.
Acceptability requirement: All health facilities, goods and services must maintain the standards of
medical ethics, such as insuring the confidentiality of individual medical information, and actually
improving the health status of those concerned. These services must also be culturally appropriate for
the people being served. Peoples traditional healing practices and medicines must be treated
respectfully.19
Important note: Acceptability may not be used as an excuse for practices tha't exclude (e.g. when
reproductive health services and information are denied to adolescent girls ‘to protect their honor').
Another limitation of the term acceptability is where traditional practices harm women’s health rights
(e.g. in the case of female genital mutilation). Such practices are considered discriminatory.
Quality requirement: Health facilities, goods and services must be scientifically as well as medically
valid and of good quality. This requires, among other things, skilled medical personnel, scientifically
sanitation
UneXp,red drUgS and hosPital equipment, safe and potable water, and adequate
i
15
A
16 tittpV/untreatY-un.orq/English/guide.asD#accession
Women. Law and Development International. 1997, page 163.
ICESCR general comment 14. paragraph 12.
ICESCR general comment 14,. paragraph 12.
ICESCR general comment 14, paragraph 12.
ICESCR general comment 14, paragraph 12.
2^
!
Beijing Platform for Action: Consensus document adopted by the 1995 Fourth World Conference on
Women in Beijing, which reviews and reaffirms women’s human rights in all aspects of life; signed by
representatives at the Conference and morally but not legally binding. The Beijing Plus 5 document
followed it, and its progress was reviewed after 10 years, during the 49Th-session of the Commission
on the Status of Women (2005).21
Benchmark: Self-set goals or targets to be reached at some future date. National and international
benchmarks are the framework for measuring progress in implementing the right to health and are
normally used for assessing the effectiveness of policies and if progress has been made in all
sections of the population.22
I
Bilateral: between two countries.
Cairo Program of Action: Outcome document of the International Conference on Population and
Development, adopted by the United Nations in September 1994, in Cairo, Egypt
I
1
Civil and Political Rights: The classical rights of citizens to liberty and equality. In principle, citizens
should be able to exercise these rights without interference from the government. Civil and political
rights include the right to life, to a fair trial, to free practice of religion, to think and express oneself, to
vote, to take part in political life and to have access to information.23
Civil society: thje voluntary civic and social organizations and institutions that form the basis of a
functioning society as opposed to the force-backed structures of a state. The term civil society is
currently often used by critics and activists as a reference to sources of resistance to globalization24.
Claim-holder: a person who is entitled to a right that a duty bearer must provide. One individual may
have both claim-holder and duty-bearer roles. The relationships between claim-holders and duty
bearers form a pattern that links individuals and communities to each other and to higher levels of
society (see duty-bearer).
Committee(s): Treaty-monitoring bodies created under various conventions to monitor the
. implementation of the treaty. Committees consist of independent experts. They examine State reports
about the application of the treaty and deal with cases involving violations of rights. See also CEDAW,
Human Rights Committee and ICESCR. The term ‘Human rights committee’ is meant to refer
specifically to the treaty-monitoring body of the International Covenant on Civil and Political Rights
(ICCPR).
Convention: See Treaty
Consensus documents: Statements of political agreement that have been adopted by declaration.
Though they are not legally binding, they are important because governments feel a moral obligation
to abide by them. They are also called political documents. One of the oldest and most influential
consensus documents is the Universal Declaration for Human Rights. Other famous examples are
the Beijing Platform for Action and the Millennium Development Goals.
21 hUp://www.un.org/womenwatch/daw/csw/index . h I n i]
77
Asher, 2004, page 89.
23 Kooijmans. 2000, page 255.
24 http://en.wikipedia.org/wiki/Civil_society
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Convention on the Elimination of All Forms of Discrimination against Women: CEDAW was
adopted in 1979 and entered into force in 1981. It is the first legally binding international document
prohibiting discrimination against women and obligating governments to take affirmative steps to
advance the equality of women.25Currently, 180 countries are party to CEDAW. In 1999, an optional
protocol (see Optional Protocol) to CEDAW was adopted, which entered into force in 2000. It
established two new procedures: a procedure for individual complaints to the Committee, and an
inquiry procedure on the basis of which the Committee can start an investigation about an alarming
situation in a specific country.
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CEDAW (the Committee): Treaty body of the Convention on the Elimination of All Forms of
Discrimination against Women. The Committee consists of a group of 23 independent experts who
monitor the implementation of the Convention by State parties. The experts have been elected on the
basis of their knowledge of relevant topics. They are nominated by governments of State parties, but
operate independently from the governments.
Core obligations: What must be done to ensure the minimum content of each right.
Covenant: See Convention. See also International Covenant on Economic, Social and Cultural Rights
(ICESCR) and International Covenant on Civil and Political Rights (ICCPR).
De facto: ‘In reality’ or ‘in fact’. A situation that actually exists, whether lawful or npt.26 See also: de jure.
De jure: ‘By law’ or ‘by right’.27 How a situation should be, according to the law. In reality, the actual
situation does not always conform with the law. For example, according to the law of a certain State
(de jure), everyone may have equal access to health care, but, in practice (de facto), due to local
customs women need their husband’s or father’s permission to see a doctor. See also: de facto.
Declaration (document): Document that contains agreed-upon standards but is not legally binding.
UN conferences, such as the 1993 UN Conference on Human Rights in Vienna and the 1995 World
Conference for Women in Beijing, usually produce two sets of declarations: one written by
government representatives and one by NGOs. The UN General Assembly often issues influential but
legally non-binding declarations.28
Declaration (statement): Sometimes a State wants to make a general statement about a treaty, for
example, the way it interprets a definition/word included in the treaty. This is done by way of a
declaration. In cases where the treaty prohibits reservations, States sometimes (abusively) make use
of declarations in order to limit the content of certain provisions or scope of application.29
Determinants of health: Conditions that make it possible to live in health, such as access to safe
water, adequate food and housing, and safe and healthy working conditions. Resource distribution,
gender differences and access to health-related education and information (including information on
sexual and reproductive health) are also health determinants. Determinants are not necessarily
directly related to health care. However, their analysis helps to make clear where barriers lie to
claiming health rights.
25
http://www.un.org/womenwatch/daw/cedaw/index
http://www.hyperdictionary.corn/search.aspx?define=de+facto
27 http://www.hyperdictionary.com/search.aspx?ciefine=de+iure
httD://www1,umn.edu/humanrts/edurnat/hreduseries/tb1b/Section3/hrqlossary.html
Information ON ratifications, reservations and declarations to specific treaties can be found on the UNHCHR website:
http://www.ohchr.org/english/bodies/index.htm
Sol
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Discrimination: “Any distinction, exclusion or restriction...which has the effect or purpose of impairing
or nullifying the recognition, enjoyment or exercise by” a group “of human rights and fundamental
freedoms in the political, economic, social, cultural, civil or any other field.”30 Groups that often face
discrimination include women, ethnic and religious minorities, homosexuals, and people with
disabilities.
Duty-bearer:; a person who is obligated to provide the rights a claim-holder is entitled to. One individual
may have both claim-holder and duty-bearer roles. The relationships between claim-holders and duty
bearers form a pattern that links individuals and communities to each other and to higher levels of
society (see claim holder).
Economic, Social and Cultural Rights: Rights that give people social and economic security. These
rights demandj-an active government policy. Examples are the right to food, education, shelter and
health care and the right to preserve and develop one’s cultural identity.31
GATS: General Agreement on Trade in Services, developed with the aim of creating a credible and
reliable system of international trade rules; ensuring fair and equitable treatment of all participants;
stimulating economic activity through guaranteed policy bindings; and promoting trade and
development through progressive liberalization. Controversial for its limitations to the freedom of
people and their governments to make democratic choices about the way their services are run and
the effect it may have on the quality and availability of essential services across the world.32
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Gender: While 'sex' refers to the biological differences between males and females, gender describes
the socially-constructed roles, rights and responsibilities that communities and societies consider
appropriate for men and women. We are born as males and females, but becoming girls, boys,
women or men is something that we learn from our families and societies. It is this learned behavior
that forms gender identity and determines gender roles. These are not necessarily the same all over
the world, or even within a country or region.33
General Recommendations/ General Comments: Documents written by the Committees that monitor
the implementation of human rights treaties explaining how a particular treaty should be interpreted
and applied. Very relevant general recommendations in the context of this assessment instrument are
CEDAW General Recommendation 24 concerning women and health and ICESCR General
Comments 14 on the right to the highest attainable standard of health.
Government: The word government is used in this assessment tool in a broad sense. It covers the law
and policy-making forces, as well as the government institutions that are responsible for the
implementation of policies. It also includes the local, regional and national government levels. While
local and regional authorities may have considerable responsibilities in developing and implementing
policies, the national (central) government has the final responsibility to ensure that human rights are
respected.
Grassroots organizations: Organizations set up by the local community and/or involving the
community.
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30
CEDAW article 1
31 Kooiimans. 2000. page 255.
32
http://www.wto.org/english/tratop_e/serv_e/gatsqa_e.htm and http://www.peopleandplanet.org/tradeiustice/gats/
3 http://www.unicef.org/gender/index bigpicture.html
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Health: Health is a state of complete physical, mental and social well being and not merely the
absence of disease or infirmity. It is not confined to health care, but includes socio-economic factors
and extends to the underlying determinants of health, such as resource distribution, gender, food and
nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy
working conditions and a healthy environment.34 See also right to health and primary, secondary
and tertiary health care.
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Human rights: The rights possessed by all persons, by virtue of their common humanity, to live a life of
freedom and dignity. These rights and freedoms are irrespective of citizenship, nationality, race,
ethnicity, language, gender, sexuality or abilities. They are universal and indivisible. Human rights .
become enforceable when they are codified as Conventions, Covenants or Treaties, or when they
become recognized as Customary International Law.35
Human rights approach: See rights-based approach.
Indicator: An indicator is a variable or measurement conveying information that may be qualitative or
quantitative, but which is consistently measurable. Indicators related to women’s health rights are, for
example, maternal mortality rate, women suffering from epidemic diseases (both transmittable and
non-transmittable), life expectancy of women, male-female ratio, nutritional level of women of all age
groups, incidence of violence against women, female literacy rate, etc. Data regarding these
indicators should be present in disaggregated form for all age groups and other socio-cultural and
economic sub-groups.36
Indivisibility of rights: The indivisibility of human rights is the basic assumption of the human rights
system, first formulated in 1948 in the Universal Declaration of Human Rights. It states that all human
rights (civil and political as well as economic, social and cultural rights) are interrelated and cannot be
separated. In order to ensure the realization of human rights, their implementation must therefore be
comprehensive. It is impossible to fully realize civil and political rights if economic, social and cultural
rights are being ignored.
International Covenant on Civil and Political Rights (ICCPR or CCPR): Adopted in 1966 and
entered into force in 1976, the ICCPR declares that all people have a broad range of civil and political
rights. It has been ratified by 154 countries as of October 2005. See also Civil and Political Rights.37
International Covenant on Economic, Social and Cultural Rights (ICESCR): Adopted in 1966, and
entered into force in 1976, the ICESCR declares that all people have a broad range of economic,
social and cultural rights. By October 2005 the treaty had been signed and ratified by 151 countries. A
group of 18 independent experts monitors its implementation. See also Economic, Social, Cultural
Rights.38
Life-cycle approach: Health is a lifetime concern. Health policies need to be tailored to the differing
challenges people face at different times in life. Discrimination or other human rights violations that
occur in infancy can determine the course of peoples’ lives.39
34
Adapted from ICESCR general recommendation 14, paragraphs 4 and 20.
36 Human Development Report 2000 Glossary: http://www.undp.org/hdr2000/english/presskit/glossary.pdf
WHO, 25 questions on Health and Human Rights,
http://www.who, int/hhr/activities/publications/en/index.html
http://www.unhchr.ch/tbs/doc.nsf
38
http://www.un.orq/Depts/Treaty/final/ts2/newfiles/part boo/iv boo/iv 3.html
39
24 http://www.unfpa.org/rh/lifecycle.htm
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Limitation: A State may have reasons to limit certain rights included in the ICESCR. For example,
public health measures to control a contagious disease might infringe upon some rights. This is
permitted only if the limitation is primarily intended to protect the rights of individuals, determined by
national law, compatible with the nature of the rights protected by the ICESCR and pursues legitimate
aims (e.g. not using the limitation to increase the military budget). Moreover, the limitation must be
aimed at the general welfare of society (e.g. not just the elite) and it must be proportional. The least
restrictive alternative must be chosen.40
Lobbying: The practice of seeking to influence the legislature or policy development to reflect a certain
point of view. Lobbying can be conducted by an individual, a group, an organization or an association.
Millennium Development Goals: The eight Millennium Development Goals (MDGs) form a blueprint
agreed to by all the world’s countries and all the world's leading development institutions. They range
from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary
education, all by the target date of 2015. In the UN Millennium Declaration, UN member states also
stress values such as freedom, equality and solidarity.41
Monitoring and reporting procedure: Treaties have a monitoring and reporting procedure to check
the implementation of the treaty in each country. In some cases the report resembles a self
inspection’ — governments report on their own compliance with human rights obligations. In others, a
monitoring body (e.g. NGOs) initiates the report on government behavior.
Non-governmental organizations (NGOs): Organizations formed by people outside the government.
They can operate on an international, national, regional or local scale on the basis of different
mandates, agendas and priorities. NGOs play a substantial role in influencing UN policy by writing
shadow reports.
Non-retrogression: The principle that governments are not allowed to remain passive in a situation
where human rights deteriorate, nor can they take measures that reduce the enjoyment of rights. If a
government takes retrogressive measures, it must prove that it had no other option, for example, due
to a severe crisis. In such a situation the government also has to demonstrate that it has protected
the rights of the most vulnerable groups.42
Optional protocol: A separate treaty associated with a parent treaty, under which state parties to the
parent treaty may choose to undertake additional obligations.43 The optional protocol to ICESCR
grants individuals the right to send a complaint to the ICESCR Committee. The optional protocol to
CEDAW also creates the possibility for the CEDAW Committee to review individual complaints
('communications’) and, above that, enables the Committee to start an inquiry procedure.
Participation- The process through which stakeholders (individuals and organizations) influence and
share control over priority setting, policy-making, resource allocation and access to public good and
services.44
40 See ICESCR article 4 and paragraphs 28 and 29 of general comment 14.
41 httD://www.ohchr.org/english/issties/millenium-dPVP|opmQnVre?Qurceg,htm
42 ICESCR General Comment 14. paragraph 32
ParticipationatProjectProgramPolicyLevel
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Policy: A purposive course of action followed by an actor or set of actors in dealing with a problem or a
matter of concern. Policies can vary considerably in scope. The term policy can refer to a nationwi e
5-year health strategy as well as to decisions of a more limited scope, such as a reduction of e
funding to the maternity wards in a certain district. The actors can be local or national governments,
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organizations, enterprises or individuals.45
Poverty Reduction Strategy Papers (PRSP): One of the conditions a country may have to fulfill in
order to receive help and debt relief is to make a PRSP. A PRSP describes the macroeconomic,
structural and social policies and programs that a country will pursue over several years to promote
broad-based growth and reduce poverty.46
Primary health care strategy: An integrated approach to improving health and socioeconomic
development defined in the Alma Ata Declaration (1978). It emphasizes community education anc
participation, addressing social determinants of health, immunization, prevention and treatment o
common and endemic disease, maternal/child and reproductive health, and access to essential
drugs.
'./i care: Primary health care is provided at relatively low cost by
Primary, secondary and tertiary health
health professionals and/or generally trained doctors working within the community and dealing with
common and relatively minor illnesses. Secondary health care is provided at relatively higher cost by
specialty-trained health professionals in centers, usually hospitals, and typically deals with relatively
common minor or serious illnesses that cannot be managed at community level. Tertiary health care
is provided in relatively few centers, typically deals with small numbers of minor or serious illnesses
requiring specialty-trained health professionals, doctors and special equipment, and is often relatively
expensive. Forms of primary, secondary and tertiary health care frequently overlap and often
interact.47
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Progressive realization: The principle that governments must do all they can to improve the situation
regarding human rights, including the right to health. They must take deliberate, concrete and
targeted steps towards the full realization of the right to health and eliminate discrimination in health
care. The speed of progress depends on the specific situation of the state and may differ from country
to country.48
Ratification/ ratified: The official promise of a state to uphold a treaty or convention and adhere to the
legal norms that it specifies.49
•(
Reproductive rights: The rights that enable all women, without discrimination on the basis of
nationality, class, ethnicity, race, age, religion, disability, sexuality or marital status, to decide whether
or not to have children. This includes the right to safe, legal abortion. These rights are basic human
rights.50
Reservation: In cases where States object to one or several articles of a human rights treaty it is
common to make use of a reservation. The reservation is a written statement that narrows the content
of the article, limits where it can be applied, or rejects the whole provision. The reservation is only
valid if it is compatible with the object and purpose of the treaty, if the treaty does not prohibit
reservations, and if other States Parties do not object to the reservation.
45 James Anderson in Howlet and Ramesh, 1995, page 6.
46 httD://www.imf.Qrq/external/no/exr/facts/Drsp.htm
47 ICESCR general comment 14, paragraph 19.
48 ICESCR article 2 and article 12; ICESCR General Comment 14 paragraphs 30 and 31.
49 http://www.undp.org/hdr2000/english/presskit/glossary.pdf
50 http://www.wgnrr.org/home.Dhp7Daqe:: 1&type=menu
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Respect/ protect/ fulfill: States parties have the obligations to respect, protect and fulfil human rights.
The obligation to respect requires States parties to refrain from interfering with the enjoyment of
rights. The obligation to protect requires States parties to prevent rights abuses by third parties. The
obligation to fulfill requires States parties to pro-actively engage in activities that ensure the
realization of rights. Fulfill also requires States to take measures necessary to ensure that each
person may obtain basic rights whenever they, for reasons beyond their control, are unable to realize
these rights through the means at their disposal.51
Rights-based approach: Because States are responsible for the realization of human rights, citizens
can hold the State accountable for its obligations to respect, protect and fulfill them. The basis of a
human rights approach is that a human rights violation needs to be addressed, even when the
number of people involved is small or not known exactly. In other words, each human rights violation
stands alone and should be taken seriously. A decrease in a certain type of human rights violation is a
positive development, but does not justify other violations still taking place.
Right to health: Health is a fundamental right that influences all aspects of life and is closely related to
other human rights. It is important to look at health as a whole. People who are ill cannot fully enjoy
their right to education or participation. Lack of food and housing, make it difficult to live in good
health. The right to health includes the availability, accessibility, acceptability and quality of health
care. See also health and primary, secondary and tertiary health care, and health determinants.
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Shadow report: Reports created by one or more NGOs that analyze the status of implementation of
human rights obligations/commitments at the national level. In these reports, NGOs provide
information that supplements government reports and thus assist the committees that monitor the
treaties to address concerns that are omitted, neglected or misreported by the government.52 Shadow
reports are also referred to as alternative reports.
Social determinants of health: the social factors affecting health, including education, access to safe
and healthy food, employment, and opportunity and control over one’s life.53
Special Rapporteur: An official appointed to compile information on a subject, usually for a limited
period.
Special Rapporteur on Health: In April 2002, the commission on Human Rights appointed Paul Hunt
as the Special Rapporteur. The Special Rapporteur’s duties are to gather and exchange information
on the right to health; discuss possible areas of cooperation with all relevant actors, including
governments, relevant United Nations bodies, specialized agencies, NGOs and international financial
institutions; report on the status of the right to health and make recommendations on measures that
promote and protect the right to health.54
State obligations: State party obligations describe what a state must do, and must not do, in order to
ensure that the population of the country is able to enjoy the rights set out in a Convention. See
Respect, protect, fulfill.
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5 httDV/shr.aaas.org/pubs/rt health/rt_health manual.pdf
52 http://swf.u2u.org/wQmen2000.txt
53 http://www.unhchr.ch/Huridocda/Huridoca.nsf/0/9854302995c2c86fc1256cec005a18d7?ODenciocurneni
54 http://www.unhchr.ch/Huridocda/Huridoca.nsf/0/9854302995c2c86fc1256cec005a18d7?Opendocument
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State(s) Party(ies): Those countries that have ratified a covenant, convention or treaty and are thereby
legally bound to conform to its provisions.55 See also State obligations.
Treaty: A contract or other written instrument binding two or more states under international law; used
synonymously with Convention and Covenant. All countries that have agreed to be bound by a treaty
through ratification or accession have a legal obligation to implement these rights and principles at
the national level.56 See also Ratification and accession.
TRIPS: WTO Agreement on Trade-Related Aspects of Intellectual Property Rights, obliging the 44
member countries of the WTO to protect the intellectual property rights on marketed products and
production processes. Intellectual property rights such as copyrights and patents are intended to
compensate the costs that manufacturers have invested in research and development.57
Universal Declaration of Human Rights (UDHR): Adopted by the General Assembly on 10 December
1948. Primary UN document establishing human rights standards and norms. All member states have
agreed to uphold the UDHR. Although the declaration was intended to be non-binding, over time its
various provisions have become so respected by States that it can now be said to be Customary
International Law.58
Violation of human rights: Breach of the commitments in a treaty (convention / covenant) or an
action/omission which is incompatible with the treaty.
Vertical program: An intervention to decrease morbidity or mortality that focuses on a specific disease
or technological solution, such as a campaign to promote oral rehydration therapy to treat diarrhea.
This is in contrast to changing more fundamental causes of illness such as malnutrition or improving
heath systems in general.
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56 Human Development Report 2000 Glossary on Human Rights and Development.
http://untreaty.un.Org/English/guide.asp#treaties
58 httD://www,wemos,nl/en-GB/Content.aspx?type=Themas&id=1548
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http://www.un.
org/Qverview/rights.html
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Annex V. LIST OF ABBREVIATIONS
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AIDS
CAT
CEDAW
CEDAW/the
Committee
CERD
CESCR
CRC
DOTS
HERWAI
HIV______
HOM
GATS
ICPD
ICCPR
"ICESCR
ILO
IMF
MDGs
NGO
PHC
PHM
PRSP
UN
UNDP
UNFPA
UNHCHR
'UNICEF
WHO
WPF
WTO
j.
Acquired Immune Deficiency Syndrome___________________
Convention against Torture______________________________
Convention on the Elimination of All Forms of Discrimination
against Women________________________________________
Committee on the Elimination of Discrimination against Women
Convention on the Elimination of Racial Discrimination________
Committee on Economic, Social and Cultural Rights__________
Convention on the Rights of the Child______________________
Directly Observed Treatment (for tuberculosis)_______________
Health Rights of Women Assessment Instrument____________
human immunodeficiency virus___________________________
Humanistisch Overleg Mensenrechten
(Dutch abbreviation for Humanist Committee on Human Rights)
General Agreement on Trade in Services___________________
International Conference on Population and Development_____
International Covenant on Civil and Political Rights___________
International Covenant on Economic, Social and Cultural Rights
International Labor Organization__________________________
International Monetary Fund_____________________
Millennium Development Goals___________________________
Non-governmental organization
Primary Health Care____________________________________
People’s Health Movement______________________________
Poverty Reduction Strategy Paper________________________
United Nations_________________________
United Nations Development Program_____________________
United Nations Population Fund__________________________
United Nations High Commissioner for Human Rights
United Nations Children’s Fund___________________________
World Health Organization_______________________________
World Population Foundation____
World Trade Organization
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