Introduction
1.Equity and Human Rights (HRs) are by no means new concepts to NGOs.
2.Moreover, Equity and HRs are inseparately linked since equity is key to the realization of HRs. The question here is what NGOs are doing with/about these two concepts in the realm of their work in health and nutrition.
3.A paradigm shift is clearly in the making in development and in health/nutrition work. New models are more politically driven in a direction that hinders and hampers the resolution of the problems at hand. Therefore, these days, more and more NGOs are discussing and trying to operationalize the ‘Equity and Human Rights-based Approach’ to apply it to their work.
The background
4.Underlying the analysis here made are several statements found in a recent publication; they read as follows:
“Most NGOs today have become very specialized and contribute marginally to the relief of poverty/ill-health/ malnutrition, but significantly to undermining the struggle of the people to emancipate themselves from oppression. Programs delivered by these NGOs do not really seek to redress the social circumstances that cause impoverishment/preventable ill-health and malnutrition. The development discourse is framed not in the language of emancipation or justice, but using the vocabulary of charity, technical expertise, neutrality and paternalism. NGO programs have often worked to undermine popular mobilization. NGOs accept or do not comment on the manner in which the State exercises its power. NGOs work is limited to project work, armed with manuals and technical tricks rather than seeking justice and standing up against violations of HR. Many NGOs were co-opted by funders to take up such a role (a typical example is health and nutrition work done to set up ‘safety nets’ for the poor). NGOs have become an integral part of a system that sacrifices respect for justice and rights, instead taking a missionary position. If NGOs stand in favor of emancipation, then the focus of their work has invariably to be in the equity/HRs/political domain, supporting those social movements that seek to challenge a social system that benefits a few and impoverishes the many”. (Manji and O’Coill, 2002)
5.Most NGOs tend to work on the issues that are before them, and forget those that are hidden away; such hidden truths have to be brought to the forefront. For example, issues of voice, power, risk and neglect are essential in a HRs discourse –as difficult to surface as they may be.
6.The fallacy that actually needs to be uprooted is that health programs addressing the urgent needs of women and children implicitly address human rights. In the HRs approach, nothing is left implicit; without an explicit retooling to a HRs focus, such claims remain but hot air; they are hollow commitments to HRs that allow controlling hierarchies to persist.
7.NGOs have ample accumulated knowledge of what is going on….and have just begun to realize that, if they do not act on that knowledge, they are not really serving the people of the communities that they work with to the fullest.
8.There is a need, then, for a more determined commitment to pro-poor social policies and programs (including health) and an increase in the funding for such an approach. Activities are to concentrate on institutional capacity building to better promote education and consciousness-raising at the community level. A key question is to give advocacy tasks more prominence so as to hold governments more accountable.
The concept of Human Rights in health and why it is used
9.In contrast to a ‘deficit-filling approach’ to poverty and preventable ill-health alleviation, the Equity/Human Rights-based approach (E/HRs-based approach) defines poverty as social exclusion. Instead of focusing on creating an inventory of public goods or services that must be provided and then seeking to fill the deficit via foreign aid, the rights-based approach focuses on trying to identify the critical exclusionary mechanisms. This, because work in health and development is about assisting poor communities overcome obstacles, rather than about the endless pursuit of grant aid for social goods.
The E/HRs-based approach enables NGOs to see much more clearly the kinds of power relations and systemic forces that drive and perpetuate poverty.
But the transition to mainstreaming a rights-based approach into the organizational structure of NGOs is a complex enterprise; it cannot simply be decreed and implemented.
10.The E/HRs-based approach asserts that work in health should be seen as a process that unequivocally leads to people fully realizing all their human rights (and not only their right to health); the approach should thus be reflected both in the processes engaged and the outcomes pursued by NGOs.
11.More importantly, the E/HRs-based approach sees ill-health, malnutrition and poverty as a denial of human dignity, i.e. as an important part of the denial of people’s economic, social, cultural, civil and political rights.
And these rights are more than just moral principles and norms governing human behavior … they are international legal standards.
Poverty itself is seen as an abuse of HRs… The poor and marginalized are not where they are by accident…
12.Because health is not the exclusive business of governments, this broad approach definitely brings an added value to communities and to NGOs when sitting down among themselves and with government representatives to jointly evaluate and plan local or national health strategies. It brings something different and potentially powerful to existing efforts by all actors in their efforts to overcome ill-health, malnutrition and poverty in a more sustainable manner.
13.The principles of equity in health (and prominently those related to gender equality) are not currently codified in any way to allow monitoring their implementation; more often than not, they are lost when implementing health sector reform or macro-economic corrective measures.
Human rights, on the other hand, are enshrined in legal covenants that protect human dignity and place obligations (or duties) on providers and others, mainly but not exclusively the State. While NGOs do have the responsibility to respect the rights of others, it is now widely accepted that states have very specific obligations to respect, protect and fulfill human rights in the realm of health and nutrition.
14.It is thus timely for NGOs to use the equity and human rights-based approach –to apply the internationally agreed human rights standards to health policy and practice– emphasizing active grassroots participation and the right of people to choose their own path.
15.When doing so, priority is to be given to the poor, the marginalized and the vulnerable –those currently most denied their rights due to their lack of choice, of control and of resources.
16.The conceptual basis that justifies (and prescribes) the use of an Equity and Human Rights-based Approach in the health and nutrition work of NGOs is the following:
- HRs are entitlements all people have, to develop their full potential; they are valid for everyone –they are universal (A right is a right only when it is universal; otherwise it is a privilege).
- There is a difference between just delivering services and making clear to beneficiaries that they are legally entitled to specific services and can go somewhere to complain if they do not receive what is due them.
- HRs objectives are not to stabilize the problems at hand, but to make them disappear by tackling them at their roots.
- HRs are pre-conditions that must be met for people to have the opportunity to live with full dignity, full health and self-worth.
- HRs lack cultural legitimacy in many parts of the world; communities are traditionally more concerned with needs than with rights; that is why NGOs have to start from people’s own initial understanding of their rights (and the issues of power) to then support a bottom-up dialogue that deepens the ownership of HRs by the beneficiaries they work with. (Without concerned citizen action to uphold HRs close to home, we shall look in vain for progress).
- Rights are different from needs; rights are relational: where someone has a right, someone else has a duty or responsibility to honor and satisfy that right. There are two critical distinctions between health rights and heath needs: first, health rights always trigger duties and responsibilities, whereas needs do not; second, health rights imply standards that can be measured whereas needs do not. Therefore, NGOs need to start thinking in terms of rights rather than needs, of rights-holders (or claim-holders) rather than beneficiaries and of enabling rather than giving.
- In the E/HRs-based approach to health beneficiaries hold claims against those who are responsible (through their actions and omissions) for their health and nutritional wellbeing. People can only realize their rights in health if they are first exposed to the root causes of the marginalization they suffer from, and if they are empowered to claim and fulfill the rights essential to their health/nutrition and livelihood security. Rights, then, have an enormous potential to attract and mobilize people. First and foremost, this means NGO interventions have to transfer ownership to the people served; key actions for this to happen are HRs education and capacity building for community members to claim and defend their rights. Empowerment here is to be understood as generating several forms of power: self-respect (power within), community cohesion (power with), and a clear agenda for action (power to).
- The E/HRs-based approach addresses abuses and/or neglect of HRs in health mostly found in the form of discrimination or exclusion. It brings to the light underlying power relationships between rights-holders and authority structures; it emphasizes dignity, equality, and participation of the former and accountability of the latter.
- Moreover, let it be very clear that advancing gender equity issues is part and parcel of work on girls’ and women’s rights in relation to health.
- Such an approach means NGOs must stand in solidarity with the poor (women, children and men) whose rights are being denied –holding themselves accountable to them (and in addition ensuring they do not violate people’s rights themselves). NGOs must support people’s efforts to take control of their own health and lives. This also includes NGOs holding others accountable for fulfilling their responsibilities, as well as opposing discrimination of any sort, addressing the root causes of poverty/ill-health and malnutrition and the corresponding rights denials in their work with rights-holders. Finally, they must work in concert with others embarked in the same endeavor (forming a supportive coalition of NGOs on these issues).
- In short, the E/HRs-based approach calls for a purposeful and transparent de-facto engagement of NGOs in the more structural aspects of the determinants of ill-health while remaining steadfast allies of local communities throughout.
- NGOs will not be alone in this E/HRs-based approach since the paradigmatic (and mindset) shift towards it is growing globally with the force of international law behind it.
- Therefore, NGOs definitely need to take steps now to improve the HRs impact of their current actions in health. This means identifying previously unforeseen gaps and opportunities. But although focusing on health, NGOs have to take into account the whole range of HRs since HRs are indivisible.
- Weighing-in on rights can risk harsh reactions from the authorities. Standing up for communities whose rights are not respected, protected or fulfilled is inevitably being political in the sense of challenging those actors responsible for abuses. So NGOs have no choice but to take a stand against authorities, policies or practices when the communities they serve are abused, neglected or excluded. The name of the game is: Remain non-partisan, but at the same time take issue.
- Even if the E/HRs-based approach is inherently about confrontation –confronting the injustices of real world situations– two approaches are possible:
- a) denouncing violations (which is often confrontational), and
- b) engaging actors in the pursuit of rights, helping them to more fully live up to their responsibilities (which is more related to promotional work).
- Monitoring HRs conditions is also very important for NGOs, and there is a need to share and disseminate information about such violations (making documented grievances public); this information will ultimately strengthen advocacy. HRs-sensitive (and gender and socio-economically disaggregated) data and indicators are critical to keeping aware of gender, equity, HRs and other issues.
- Despite growing clarity about all the issues above, there is no one blueprint for an equity and human rights-based approach to programming in health; each NGO will have to go through its own retreat(s) to revision and remission their mandates to adjust their very own approach and programs to it. (Adapted from CARE, 2002)
Claudio Schuftan, Ho Chi Minh City