( Department of MDGs, Health and Development Policy (HDP) and the health and human rights team in the Department of Ethics, Trade, Human Rights and Health Law (ETH), both part of the Cluster of Sustainable Development and Healthy Environments (SDE) of the World Health Organization (WHO). Penelope Andrea of WHO, Paul Hunt, UN Special Rapporteur ,and Judith Bueno de Mesquita, University of Essex
Countries worldwide are making considerable efforts to achieve the Millennium Development Goals (MDGs), that aim to dramatically reduce poverty, ill-health and inequality, as well as increase access to education and improve environmental stability. For most, these efforts are channelled into designing and implementing a national Poverty Reduction Strategy (PRS).
Operationalizing and realizing human rights principles in practice is rarely straightforward, particularly in view of the financial and political constraints faced by all countries. Nevertheless, there is increasing evidence that human rights principles can and have been successfully used to underpin strategies and initiatives designed to help poor and marginalized communities, whether at the early planning stages or later in implementation, monitoring and evaluation.
Elements of a human rights-based approach
A human rights-based approach to development programming differs from conventional approaches in that it emphasizes the process by which it is undertaken as much as the outputs or measurable results. Crucial to this process is the principle of the right of all stakeholders to participate in the design and implementation of any policies affecting them. In addition, it is stressed that human rights-based policies and programmes must address the immediate, underlying and structural causes behind the non-realization of human rights.
A human rights-based approach focuses on the capacities of both the claim-holders and the duty-bearers. Claim-holders may be individuals or groups whose human rights are to be respected, protected and fulfilled. Duty-bearers, on the other hand, are those who have the responsibility (and hold the power) to bring this about.
The state is the principal duty-bearer and as such, human rights-based development policies are primarily concerned with the actions required of the government. However, the state is equally responsible for ensuring that the behaviour of others, including non-state actors, community leaders and even family members, who hold some power in determining the extent to which an individual’s human rights can be fulfilled, live up to their responsibilities.
In addition, states are also required to take all possible steps, either individually or in cooperation with others, to support one another in their endeavours to meet their human rights obligations. A comprehensive policy will therefore encompass the entire enabling environment necessary for human rights to be allowed to flourish.
Health is protected by the human rights legal framework
Health and Human Rights :
Reducing vulnerability to ill – health :
- Right to infomation
- Right to education
- Right to food and nutrition
- Right to water
Promotion of Human Rights through Health Development :
- Right to Participation
Underlying determinants :
- Health care
- The Right to health
Under the right to health, states are obliged to ensure that public health services, as well as medicines and health care staff, are made available to all, are accessible to all, regardless of geographical location or economic status and are acceptable to all cultures, genders and ages and respect the privacy of all individuals.
In addition, the quality of the skills of the health personnel, the medicines available and the equipment used should be of a consistent standard for all communities and all individuals within those communities.
In addition to the provision of health care, it is generally understood that the fulfilment of the right to health depends upon a number of related human rights that can have a direct impact upon health. These include the right to safe water and sanitation, the right to food and nutrition, the right to shelter, the right to occupational and environmental conditions that do not damage health, the right to health-related education and information, the right to non-discrimination, the right to participate, the right to enjoy the fruits of scientific progress and the right to social security or protection in times of severe hardship.
Under international law, some of the obligations of the duty-bearers are immediate and may not necessarily imply significant financial outlay. A government must take immediate action to:
Halt any actions or other measures that are having a detrimental effect on the health of any individuals or groups;
§ establish ways in which all stakeholders can participate in shaping the policies that will affect them;
§ take concrete steps, including financial and political commitments, that will eventually meet longer-term obligations;
Other obligations are harder to achieve immediately. Human rights law recognizes the severe resource constraints that poor countries face and requires instead that governments embark on a long-term plan that will lead to the progressive realization of human rights.
Developing a comprehensive pro-poor national public health strategy, or a Poverty Reduction Stratgy, is a concrete way in which a government can demonstrate that it is moving towards the realization of all human rights related to health. It should strive to allow affected populations, i.e. poor and vulnerable population groups, to participate in the diagnosis of the situation and in the design, implementation and evaluation of the strategy.
It should specify goals and indicators of progress and identify mechanisms, whether already in existence or newly created, that can play a role in monitoring progress towards realizing the different dimensions of the right to health.
A government must also work towards fulfilling other rights that can have an impact on health. Many of these associated rights traditionally fall outside the authority of the ministry of health (MOH). The challenge then for any government is to ensure these are given equal priority by all ministries and departments.
Ensuring access to safe water and sanitation, protecting the living and working environments of communities, providing access to information and education related to health matters and ensuring no international agreements entered into by the government, such as trade laws or loans, are harmful to the health of the poor is as important as the traditional approach of focusing just on providing primary health care.
Developing a PRS provides an excellent opportunity for the government to address all these areas and to foster cohesion across all sectors and ministries.
Human rights approach help to define poverty
Poverty has conventionally been defined in economic terms, focusing on an individual’s or household’s available financial capacity, both either absolute or relative.
In recent years, however, alternative views have emerged that now recognize that poverty is multidimensional.
It can be defined not only as lack of material resources deemed necessary for an acceptable standard of living, but also a denial of other related capacities and opportunities, such as education and physical well-being, as well as less easily quantifiable factors such as lack of dignity, self-respect, freedom or access to power.
Poverty Reduction Strategies
A Poverty Reduction Strategy ( PRS ) is a national cross-sectoral development framework, designed and implemented by national governments, specifically to tackle the causes and impact of poverty in a country.
In low- and middle-income states, PRSs were initially introduced as a requirement for countries seeking concessional loans from the World Bank or the International Monetary Fund (IMF). Today, PRSs are increasingly seen as the principal mechanism around which many bilateral and multilateral donors build their development cooperation programmes.
There is now broad agreement among all the leading development agencies, including the World Bank, on the key principles on which PRSs should be based:
§ They should be driven by the needs and wishes of the country concerned.
§ They should be founded upon a broad-based participatory approach - from initial diagnosis, to design, and on to monitoring and evaluation.
§ They should be results-oriented and focused on outcomes of specific benefit to the poor.
§ Analysis and diagnosis of the nature and causes of poverty should take account of its multidimensional nature, not merely income poverty.
§ Data used to define the extent and location of poverty should be as disaggregated as possible to clarify the complex, structural and social, as well as economic, underlying causes.
§ With limited resources, any policy that is to be sustainable will inevitably require an element of prioritization.
§ Prioritization implies trade-offs, which in turn require short-, medium- and long-term targets, benchmarks and indicators for the evaluation of progress, and adjustment of priorities as circumstances change.
§ Progress must be monitored and evaluated in partnership with those for whom the strategy is designed and should be based on a long-term view of poverty reduction.
§ Mechanisms that foster and promote transparency and accountability of those charged with designing and implementing the strategy must be established and sufficiently resourced.
Human Rights and Poverty Reduction Strategies complement each other
Any national policy should be consistent with the government’s international human rights obligations.
There are a number of significant and supplementary advantages that add to the compelling argument of adopting a human rights-based approach to the development of a PRS:
§ Rooting a national policy in an international legal framework strengthens the centrality of the state in design, implementation and oversight of PRSs.
A PRS founded on human rights principles is an effective mechanism whereby a state can gradually achieve its longer-term obligations.
- Any PRS, to be effective, legitimate and sustainable, depends upon the empowerment of the poor and human rights are effective tools of such empowerment.
- While other approaches focus on raising average indicator levels, a human rights approach can ensure that it is the most vulnerable, including the poorest of the poor that are targeted.
- The resource constraints facing poor countries are recognized by both PRSs and human rights law under the principle of progressive realization and both frameworks recognize the importance of an enabling environment, including that dependent upon the wider international community and non-state actors.
Formulating a pro – poor health strategy based on Human Rights principles
Nature of poverty in the country
Although human rights instruments do not provide an easy checklist for analysing the nature of poverty in a country, the extent to which they are fulfilled and respected can certainly serve as indicators of poverty.
The following are just some of key questions that should be asked when embarking on a process of identifying instances of poverty:
§ Is everyone sufficiently well nourished?
§ Is enough adequate shelter available for everyone?
§ Can all children, girls and boys, receive a basic education?
§ Can all heads of household, male or female, earn sufficient resources to provide for their families?
§ Are some people dying prematurely from preventable causes?
§ Are some people or communities without access to health care services?
§ Do some individuals or groups of people suffer from discrimination or feel threatened with violence or injury from others?
§ Does everyone have access to justice and the legal system?
§ Do all people have a means of voicing their opinions and wishes?
The poor and where are they
Once the nature of poverty within the country has been identified, the challenge then is to identify not only how many people are affected but more importantly who they are and where they are located. The key human rights principles of non-discrimination and equality of all people require that the poor are not merely represented as a percentage figure but are clearly identified as groups and individuals. These principles can guide a process of disaggregation which will be necessary to extract this information from the overall available data.
The number of women living in poverty is increasing disproportionately to the number of men, particularly in the developing countries. The feminization of poverty is also a problem in countries with economies in transition as a short-term consequence of the process of political, economic and social transformation.
Looking closely at various vulnerable groups within a country and comparing the levels and extent of multidimensional poverty found within them against that of the rest of the population is an important stage in the process of developing a sound PRS.
Some of the groups that have been identified as frequently being more vulnerable to poverty include:
§ women and girls;
§ indigenous and tribal peoples;
§ children living in difficult circumstances, e.g. street children, orphans, etc.
§ the elderly;
§ remote rural populations;
§ communities living in particular locations or substandard housing, e.g. slum dwellers;
§ internally displaced persons;
§ the unemployed or homeless;
Ways in which poverty affect the health of the poor
A close look at health care services available in the country may reveal that for whatever reason, those living in poverty do not enjoy the same levels of care and treatment as other people. Some may not be able to access any health care at all.
It may also reveal that poor people are less able to enjoy protection against ill-health that is available to others in the country.
A wider understanding of the effects of poverty on health should include:
§ an analysis of the extent to which poor communities have access to information concerning their health or that of their families;
§ the quality and availability of potable water, sanitation and nutritious food without which their health may suffer;
§ the conditions of housing and shelter and whether these may be in any way endangering the health of the inhabitants;
§ the extent to which poor communities are able to express their wishes and opinions concerning their health needs and the services available to them;
§ the system by which health care is usually paid for, whether through direct fees or through forms of insurance or social security.
To be truly effective, any health component of a PRS should address these wider causes and include interventions that may traditionally lie outside of the scope of the national health policy.
Underlying causes
The final stage in the process of developing the health component of a PRS is to consider why poverty is continuing to affect the health of the poor.
Asking the poor themselves to participate in the process of identifying the underlying causes is the most effective means of bringing to light the real reasons and pin-pointing the most effective points of intervention.
The challenge facing those preparing a national strategy is to identify not only where the responsibilities lie but equally, where capacities may be lacking or withheld and then formulate a policy that addresses this.
At the community level, additional factors may affect some members of the community.
For example:
- Cultural norms or taboos may hinder some members of the community such as those affected by illness or disability from participating in community life or seeking care and treatment.
§ Health services available at the community level may be inappropriate, insufficient or underutilized by some members of the community for economic or cultural reasons.
- Health centres may be located in inaccessible positions for some communities.
§ Communities may have had little to say in defining their needs or the scope of the health services available to them.
- Environmental or infrastructural factors may be preventing the community from accessing available services promptly when needed at all times of the year.
- Corruption or prejudice of local health professionals too may be a major factor in deterring poor communities from seeking treatment and care.
Within the health service, wide discrepancies in the quality and availability of care between wealthier urban areas and poor rural communities is a frequently witnessed phenomenon:
§ The physical availability of health facilities or outreach mechanisms for all parts of the country at all times of the year is often overlooked.
§ Health centres should also be equally well equipped and carry sufficient supplies of medicines and vaccines and have the appropriate storage facilities.
§ The services provided may sometimes be inappropriate for the local needs or be delivered in ways that are offensive or unacceptable to some ethnic minorities or religious groups.
§ The health services sector must ensure that sufficient qualified and motivated staff are available at all health centres, are fulfilling their roles and are treating all their patients with the same dignity and courtesy, regardless of their gender, age, ethnicity, health status or level of poverty.
§ Health centres sometimes impose unaffordable financial burdens on those seeking medical treatment which will inevitably discriminate against the poor.
At the national level, some decisions and policies of the Ministry of Health or Ministry of Planning or Ministry of Justice, may harm or disadvantage the health of poor or marginalized communities.
§ Overall budget allocations may be based upon the prioritizing of issues (e.g. defence or tourism) other than human rights such as the right to health.
- Decisions around the setting of health budgets may result in insufficient funding of health services for some parts of the country or a concentration in urban areas.
- The mechanisms deployed for raising revenues for public health, such as user fees or insurance schemes, may penalize the poor.
§ Decisions on prioritization may seriously reduce the cost-effectiveness of health care for the poor.
- Insufficient information may be available on health matters and on available services or may exist only in some formats that are of little benefit to the poor.
§ The availability and quality of essential drugs may not be sufficient to meet the needs of the whole country due to inadequate procurement or licensing rules.
- Services delegated to the private sector may be unregulated with little government oversight.
- In the processes of descentralization and reform of the state, little understanding of the development of capacities in the descentralized and local levels produce underinvestment in Health and Human Rights areas.
At the international level, special effort should be made to scrutinize and understand the impact on the health of the poor of each international agreement and every multinational company as part of the poverty assessment undertaken by the Ministry óf Health, the ministries of social areas, etc.
In recent years, an increasing number of public/private partnerships have emerged. They fall into two main groups: those concerned with research and development (R&D) of new drugs to tackle diseases neglected by the commercial R&D sector; and those concerned with addressing specific health challenges, such as immunization and HIV/AIDS, at country level.
However, when looked at from a human rights perspective, it is important to ensure that their success does not allow attention and support to be diverted away from broader health systems issues such as human resources and strengthening health information systems.
Some development policies advocated by international donors may have been founded upon tried and tested long-term economic principles but, in some circumstances. have called for cut-backs in social spending, particularly in the health sector, exacerbating the already limited access the poor have to health care and treatment.
Article by Pedro Enrique Quinones Figueroa, MD, MPH, Project Manager.
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