112. HOW IS THE HUMAN RIGHTS-BASED APPROACH TO CHANGE THE ETHICS AND PRAXIS OF ACHIEVING UNIVERSAL HEALTH COVERAGE?*

Editorial, Social Medicine/Medicina Social, Vol.10, No.2, August 2016, pp.36-40.

Claudio Schuftan MD,
People’s Health Movement, Ho Chi Minh City.
cschuftan@phmovement.org
*: The views herein are the author’s.

The setting

The human rights-based approach to health work comes to reinvigorate old time health activists who, for long, had been advocating and fighting for a more political approach to providing universal access to health services. (Schuftan. 2005) The human rights-based framework being applied reminds us that only when those relegated to live in poverty are understood to be the most effective analysts of their own problems and to be the best agents of their own solutions, is it possible to formulate effective and sustainable interventions. (Lewis. 1999) The adoption of this approach is, therefore, a step towards further politicizing the development paradigm as it applies to health. (Schuftan. 1988) Conversely, avoiding the politics of it all ends in coming up with options too timid and too narrow. It has taken us years to figure this out. The stark reality is that there is no escape from politics, no way to represent the social world free of ideology. And keep in mind, a political climate is something one creates, not something that is found out there. What you actively push is what you will change.
The human rights discourse applied to UHC

The Human Rights discourse resurrects a return to a greater focus and action on the structural causes of preventable ill-health, preventable malnutrition and preventable premature deaths which still remain mainly under-addressed particularly for a lack of focus on their structural determinants. (UNICEF. 1990)
Human rights work applied to UHC breaks the silence of powerlessness that keeps the needs and desires of poor and marginalized people from being part of national political agendas. For the disempowered to get voice is not enough; human rights work is about getting them influence –and about the processes that lead from having voice to having influence.

When a little is not enough

Taking a ‘minimalist stand towards peoples’ right to UHC will do no harm, but neither will it do much good. This, because the neoliberal development paradigm has led to consistently adopting soft solutions when faced with hard choices. (For instance, ‘safety nets’ are nothing but part of a strategy to manage poverty so as to attenuate social unrest, keeping it at a minimum).

Moreover, the choice of patch solutions makes measurable statistics (as for instance those being proposed for the SDGs) their primary goal –not participation, not equality, not human rights. This is but one example of ‘when a little is not enough’.

Commitment to change coming from technical and/or ethical imperatives alone does not fuel great social movements anymore. It is not enough to encourage the articulation of a shared moral vision, because it leaves us unable to consolidate this vision into moral outrage and that outrage into political power to change an unfair state of affairs impinging on the rights of people –UHC included. Remaining politically passive, we cannot even expect any fundamental change, except that of the awful slow variety where each step takes two generations or more.

Actually, both soft (ethically-motivated) and hard (politically-motivated) approaches to the right to UHC are necessary. But the former alone is simply not sufficient; both call for a profound commitment. The bottom line is that there will be no more business as usual. This is thus a key time for reflection and soul searching. (Schuftan. 2006)

We need moral advocates to influence perceptions. Granted. We need mobilization agents and social activists to influence action. Granted. But we also need political advocates to raise political consciousness and provide leadership. The latter cannot be left for later. Therefore, agreeing on the politics of the right to UHC –beyond ethical pronouncements– is the real challenge.

The neoliberal straightjacket impinging on health

Much is being said these days about UHC. But also, much of what is said, does not propose a unified, all-encompassing system of public provision. (Coverage rates are usually presented as averages thus hiding often enormous inequalities!). The UHC model talked-about-most provides ‘choices’; yes, but within a particular political and economic environment that is not neutral. The dominant neoliberal environment does exploit the ambiguities of the UHC model and pushes a model that is market and (private) insurance driven –an anathema to what the human right to health stands for. (Turiano and Smith 2008) We understand efficiency in health care not in the way used in a market environment, but in terms of the returns achieved through investment in a public good, through a single payer system.
Breaking in into the human rights paradigm

To apply the human rights-based approach in everyday work to achieve the realization of UHC undoubtedly calls for a paradigm break or shift. But so far, this break has only been conceptual, not yet operational. In its operationalization, the human rights paradigm will have to become more overtly and explicitly political with the creation of well organized claim holders’ pressure groups among those whose rights are being violated. And to transcend minimalism, these groups will further have to rapidly coalesce into bigger movements –a challenge, among other, for progressive Internet sites and lists. But beware, it is not enough to go forward using a soft approach in promoting the new paradigm.

We rather need to start from the people’s felt needs, translate those into concrete and effective demands, that bring about people’s organizations to start exercising growing, de-facto power, and then consolidating (their newly acquired) power with that of other like-minded similar organizations.

What is thus needed is to counter a host of complex social and political issues that are preventing people from improving their health –and these are mostly related to control processes in society. (Commission on the Social Determinants of Health. 2008)

Without following the ethical and political imperatives to apply human rights principles to it, UHC will remain a toothless and idle slogan, and overwhelmingly serve the interests of the ‘haves’, especially insurance companies.

Getting from here to there

It is true that many an international and national meeting on UHC is ongoing as the UN Secretary General is persistently asking for ways to operationalize the human rights framework in all domains of development.

We cannot look the other way: the fundamental changes needed to realize UHC are not possible without entering into conflict with the powers-that-be. The call thus is for our praxis to make it a reality.

But because there is no progressive politics without the masses, only political mobilization of claim holders will do. Otherwise, we may have to wait for another ten years (or two generations…?).

We are talking here about a practical, hands-on mobilization: a mobilization for lobbying, for placing demands, to fight for people’s economic, social and cultural rights (since rights are indivisible), i.e., to exert active resistance to social injustice. Such a mobilization has to lead to an empowerment where popular demands are made into concrete action proposals. (Schuftan. 1990 and 2003)

Human rights in the era of globalization

Under globalization we live under the rule of “Might is Right” and, under the rule of that might, comprehensive UHC (and human rights) just fall between the cracks. Globalization does not have a human face. The term globalization is a euphemism for a process of domination. Power differentials are at its crux. We cannot wish this away.

When governments agreed to become signatories of the Economic, Social and Cultural Rights Covenant they, knowingly or not, agreed to the new human rights paradigm; it is for us to apply it for true UHC. What this means is that states have the duty to improve the fair distribution of and access to health care. And we have to hold them accountable for it.

Many current health policies are not human rights-friendly. They certainly do not demonstrably give protection to the most vulnerable and impoverished in society. Our action as watchdogs of the enforcement of an equitable UHC is now called for. (And never forget: The duty to fulfill the right to health does not depend on economic justifications or excuses). (Lewis. 1999)

Pleading Guilty

As health-and-human-rights–workers-acting-as-political-activists we have to be willing to come into conflict with the ideology of the ruling minority proposing approaches to UHC that disregards human rights. For that to happen, we need to demystify the ideology of power-taken-as-being-neutral in the ruling development paradigm.

Moreover, objectively, there is not yet among our peers a felt responsibility for the creation of national and international conditions favorable to the realization of UHC using the human rights framework.

Because of this, most of us stand accused for our complacency towards the status-quo and towards violations of the right to health. We must come out to critique the overall lack of progress in implementing true UHC policies. Just uncritically ‘doing something’ is not enough. We cannot escape taking part of the blame.
What we have not yet done

First and foremost we must translate this approach to the domestic level. Snail-pace progress in implementing UHC by governments goes against their ratification of international human rights covenants. Our work will thus require committed leadership to expand popular demands for UHC focused on ensuring claim holders’ democratic participation to secure improvements in the incomes of the poorest and, yes, universal access and affordability of quality health care (especially for women and children).

As a start, at the country level, we need to check on the follow-up each country has made on major recommendations from international health and human rights conventions and regional conferences that their governments endorsed when they attended.
Steps also have to be taken to clarify the universal minimum core content of human rights applied to the realization of UHC in each country. Furthermore, existing health policies that are not in conformity with expected human rights principles and standards have to be openly contested.
Where to start?

In the work ahead, dreaming is OK, but being naïf is not.

On most of the issues here depicted, we do not exert effective political leadership yet. But we cannot run away from showing intellectual leadership at least. All of us are called upon to help legitimize and enforce all UN-sanctioned people’s rights, and that requires a crucial change in our conceptual thinking, a change of our mindset. Only thus will we see comprehensive UHC being achieved in our life times.

Furthermore, we urgently need to contribute to the setting up and strengthening of National Human Rights Committees or Commissions.
To this, we will have to add the needed work at grassroots and mass organizations level to make clarity to all about what these rights are and mean in practice for the achievement of UHC. This will have to be followed by the launching of the social mobilization and empowerment processes needed to pursue the path alluded to earlier. (Cornwall and Brock. 2005)

Additionally, what we need to, is to:
• strengthen the capacity of health workers to apply the human rights principles to UHC; (Lewis, 1999)
• overcome the culture of apathy of this staff around right to health issues; this means they will have to work more directly with communities;
• eliminate in the same staff’s minds the division they see between politics and their professional endeavors;
• not wait for opportunities, but create them. [Rights have to be taken; they are not given!]; we need to “walk the talk and not talk the talk”;
• monitor the intentions and deeds of governments and donors to implement UHC in the realm of economic, social and cultural rights.

The overall call is for us to move from seeing UHC as a basic human need –which only bring promises– to seeing UHC as a human rights issue –which calls on states’ correlative duties. In the latter, the recipient populations are actually bona-fide claim holders. The added value of the rights-based approach really lies in creating and enforcing the legal accountability needed and in legitimizing the use of political means in the process of enforcing, in our case, UHC. The establishment of national and international complaints procedures is, therefore, also needed. It is public interest civil society organizations that need to take up this function on their own shoulders.

Epilogue

What has been said here, is not pure rhetoric. There are some important normative messages here. I see the endeavor we are asking our peers to embark-on as the opening of the nth chapter of a long-term painful struggle on these issues that desperately attempts to make UHC a reality. We need you to act proactively and not only react. Everywhere.

We are in for exciting new times. We need all the courage we can muster. Wouldn’t you rather become a protagonist than a bystander?
There is a big catch up task to be undertaken to remedy past wrongs and making the next decade a winning decade for UHC and for human rights. Never be sorry to be too late.

References

Commission on Social Determinants of Health. 2008. Closing the gap in a generation. Health equity through action on the social determinants of health. World Health Organization.
Cornwall A. and Brock K. 2005. Beyond buzzwords ‘poverty reduction,’ ‘participation’ and ‘empowerment’ in development policy,” Overarching Concerns Programme, Paper No. 10. (Geneva: United Nations Research Institute for Social Development). Available at http://www.unrisd.org/80256B3C005BCCF9/(httpAuxPages)/F25D3D6D27E2A1ACC12570CB002FFA9A/$file/cornwall.pdf
Lewis, S. 1999. Malnutrition as a human rights violation: Implications for UN-supported programmes. SCN News, No.18, July.
Schuftan, C.1988. Multidisciplinarity, paradigms and ideology in national development work. Scand. J. of Dev. Alts. VII:2+3.
Schuftan, C. 1990. Activism to face world hunger: Exploring new needed commitments, Soc. Chge., 20:4, December.
Schuftan C. 2003. Human rights-based planning: The new approach. The Ecology of Food and Nutrition. 42:1, pp.32-39.
Schuftan, C. 2005. The human rights discourse in health. Perspectives on Global Development and Technology. 4:2, pp. 245-250.
Turiano, L. and Smith, L. 2008. The catalytic synergy of health and human rights: The People’s Health Movement and the Right to Health and Health Care Campaign. Health and Human Rights. 10:1, p. 143-153.
UNICEF.1990. Strategy for improved nutrition of children and women in developing countries: A UNICEF Policy Review. E/ICEF/1990/L.6, New York, March.

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