Chapter in Health For and By the People, CETIM, Gva., Jan. 2007.
Claudio Schuftan MD, People’s Health Movement, Vietnam, schuftan@gmail.com
Abhay Shukla, MD, People’s Health Movement, India, abhayshukla1@gmail.com
-We find ourselves at a crossroads: health care can be considered a commodity to be sold, or it can be considered a basic social right. It cannot comfortably be considered both of these at the same time. This, I believe is the great drama of medicine at the start of this century. And this is the choice before all people of faith and good will in these dangerous times. – Paul Farmer
-Rats and roaches live by competition under the law of supply and demand; it is the privilege of human beings to live under the laws of justice and rights. – Wendell Berry.
The context: What is needed
1. The large scale weakening of public health systems, the unchecked privatisation of health care in its various forms and the erosion of universal access to health care are phenomena seen across the globe in the current phase capitalist globalisation. The global health sector discourse is dominated by vertical, selective and technocentric approaches, often supported by ‘public-private partnerships’ active at global, national and local levels; consequently, these are the preferred components of modern-day health sector reforms the world over. There is thus an urgent need to replace this dominant discourse by a process aimed at universally achieving the ‘right to health and to health care’ as the main objective to get more equitable health care systems implemented in both developing and developed countries. Ergo, in order to counter and reverse the tide promoting ‘health care as a commodity’, there is the imperative to reach a strong global consensus on ‘health care as a right’, as well as to begin using (and fighting for) international and national provisions that effectively support this right and that will strengthen public health in a lasting manner. It is in this context that embarking on a global initiative to strengthen the ‘Right to Health’ (RTH) with a focus on defending and operationalising the ‘Right to Health Care’ is discussed below.
2. We will depart from the perspective that human rights (HR) are respected when everyone has adequate food and nutrition, decent shelter, good education and good quality health care (–and the poor effectively claim these rights).
3. Violations of these rights are not accidents; they are not random in distribution or effect; they are linked to social conditions that determine who will suffer abuse and who will be spared. In each local context, it is thus the social forces (dialectically) at work that determine the risk of most forms of human rights violations, as well as determine the prevailing ‘climate’ of economic and social justice.
4. Ongoing human rights violations somehow fail to draw on our deeper understanding of the social, economic and political determinants of the wide variety of ills (and abuses) we see –this lending them a random appearance when, in fact, they are a highly predictable set of outcomes.
5. The question then is: since laws designed to protect human rights are mostly not applied at all, what additional measures have to be taken? This is what the RTH approach sets out to explore.
6. Human rights abuses are best understood from the point of view of the poor. It is mostly them who are the victims and they have too little voice and no influence, let alone rights. The poor are not only more likely to suffer; they are also less likely to have their suffering noticed. The more there are suffering human beings, the more neutral their suffering appears to the public.
7. We, therefore, cannot fail to study and to do something about violations to the right to health; but we cannot study them out of the context of culture, history and the prevailing political economy. For that, we must move beyond just good situation analyses.
8. Invoking ‘cultural differences’ is one of several ways to explain away assaults on dignity and on human rights. As may be expedient, oppressive practices are said to be part of ‘the local culture’. These are analytic vices we have to combat. Culture per-se does not explain human rights violations –it may, at worst, furnish an alibi. So, we need to ground our understanding of human rights and right to health violations in the broader analyses of power, socioeconomic inequality and injustice.
9. It is inequities of power that prevent the poor from accessing the opportunities they need to move out of poverty. Denying this only serves the interests of the powerful. Structures and not just individuals must be changed if the world is to change.
10. The promotion of equity is the central ingredient for respecting human rights in health. Cost-effectiveness improvements may be relevant, but do nothing to reduce inequity. Let us be reminded that poverty results from the actions of other human beings; it is the result of man-made structural violations. Moreover, poverty –part and parcel of the global free-market system– is the world’s greatest killer. It is not enough to improve the situation of the poor within the existing social relationships. The poverty of the poor demands that we build a different, more just social order. Under neoliberalism, policies actually erode the right-to-freedom-from-want.
11. In health, we cannot therefore simply worry about poor or lack of access to health care; we have to link that to social and economic rights in general. For too long, health has been only peripherally involved in work in human rights. But health does offer a very critical dimension to the human rights perspective.
12. Just passing more human rights legislation is not a sufficient response either, because those in charge already disregard many of the existing, but non-binding legal instruments. Laws alone –without enforcement mechanisms (triggered and controlled by the people)– are not up to the task of relieving the immense suffering already at hand. Ultimately, laws are ‘normative ideology’ and are thus tightly tied to the prevailing power relations.
13. We ourselves risk being implicated-in and being oblivious to the increasingly global structures that are actually violating human rights. If we stay in our ivory towers, human rights can reduce us to seminar-room warriors. At worst, we risk standing revealed as hypocrites. Why? Because, in human rights work, research and critical assessment alone are insufficient. No more adequate is denunciation alone. Knowing carries obligations –thus the proposed RTH approach.
14. To work on behalf of and with the victims of human rights violations invariably means becoming deeply involved in pressing for social and economic rights. The fact that we have failed to enforce the right to health does not imply that the next step is to lower our sight; rather, the next step is to try a new, more effective approach. The proposed Campaign is such an outlet. ???
15. The Right to Health is perhaps the least contested social right. Public opinion is overall sympathetic to the RTH (more so than for other rights). Advocacy in this field has thus failed miserably. Somehow, we have failed to link public health to the achievement of greater economic and social justice. Denial of care to those who do not pay is simply legitimised in the free-market system. Ergo, the struggle for equity is actually the central challenge for the future of public health (that is why some speak of the ‘right to equity’).
16. So, social and economic rights are at the heart of what must become the new medical ethics –an ethics of distributive justice. We simply must protect those most likely to suffer the insults of structural violence. The real energy to find workable solutions can only come from the oppressed themselves.
17. Better sooner than later, we have to embark on a process that roots out the structural problems underlying widespread human rights violations. Here proposed are steps in that direction.
The justification we should use when facing our opponents
18. The majority of countries around the world –over 150– are parties to the International Covenant on Economic, Social and Cultural Rights. ‘General Comment 14’ (GC 14) of the UN’s Commission on Economic, Social and Cultural Rights (CESCR) adopted in the year 2000 elaborates on and clarifies the Right to Health by unmistakeably defining the broad content, methods of operationalisation, violations and suggested means to monitor the implementation of this right. Over ten years have passed since the launching of GC 14 –the most comprehensive internationally adopted instrument mandating the Right to Health. However, there is now a need to launch a global process of mobilization to actually implement the provisions of GC 14 in all signatory countries. This clearly calls for measures to operationalise the ‘Right to Health’ and to review and recast all global and national health sector (reform) initiatives (such as, for instance, those reforms pursuing the MDGs) in the light of the overarching framework of health as a right.
Why a RTH campaign?
19. It is our moral and political obligation to work towards strengthening the Right to Health and working for universal access to health care systems. But there are a host of other reasons to intensify our work on the RTH. Among them are the fact that the Basic Needs Approach (has) never delivered; moreover, health has become commoditized and the Human Rights-based Approach (HRBAP) is the new UN policy; additionally, HR principles are enshrined in and backed by international law.
20. [It is noted that the People’s Health Movement (www.phmovement.org ) is founded around the principle of a right to health and to equitable access to health services at all levels and with no discrimination. The Movement (PHM) sees all aspects of the RTH as relevant. Why is PHM suggesting to first focus on the Right to Health Care? PHM struggles for and demands the respect of all aspects (the full range) of the RTH. But, to centre its actions, it is indispensable to focus; the campaign they are launching will thus initially focus on the right to health care. This focus, by itself, will be a monumental challenge. PHM will join/support and co-initiate campaigns with all its strategic allies working on the other aspects of the RTH but, as PHM, it will first focus and take the lead on the RTH Care; its strategy in the first phase is thus to take the lead role nationally and globally in pursuing the respect of the Right to Health Care –i.e., taking primary responsibility for gathering evidence, documenting violations and taking direct action on the latter. This idea is clarified by the following three diagrams:].
AVAILABLE FROM TE AUTHOR
21. Here, we suggest all readers join the struggle for all aspects of the RTH. But, you also have to centre and focus your efforts: pick your choice.
What is the added value of adopting a HR-based approach to health?
22. Several advantages come to mind: The new RTH approach has a big social mobilization potential –and this is an indispensable part of any future work; as said, the HR approach is backed by international legislation; the RTH approach demands –from a position of power– that decision-makers take responsibility; human rights imply ‘correlative duties’ of decision-makers that have control over needed resources; these correlative duties are universal and indivisible (there is no such a thing as ‘basic rights’); the HR approach is focused on processes that lead to outcomes (setting goals, like the MDGs, is thus not sufficient in the HRBAP!). Charity has no room in the HRBAP since the latter demands the fulfilment of duties and obligations. The HRBAP considers these duties and obligations being part of a veritable social contract explicated in the various UN HR covenants signed by the majority of countries around the globe.
What does the RTH imply?
23. In every development process there are two types of actors: claim holders and duty bearers. Claim holders have to demand their rights from the duty bearers; if they do not do it, it is in part their fault.
The RTH is thus currently being violated, because a) claim holders do not have the capacity to effectively demand (claim) their rights, and b) because duty bearers do not have the capacity to fulfil their obligations (correlative duties).
24. Therefore, in the HRBAP one has to carry out two types of analyses: a) situation analyses in which one determines the causes of the problems placing them in a hierarchical causality chain of immediate, underlying and basic causes or determinants, and b) capacity analyses in which one determines who are the individuals/institutions that bare the duty to do something about the above causes calling them then to fulfil their duties as per their countries’ obligations as signatories of the said UN HR covenants.
These two types of analyses have to be carried out with the community and the beneficiaries of the health system so that the rights being violated can be identified jointly –and those responsible can be confronted for them to do something about the problems identified.
25. The last thing we want is to look for health policies that favour the poor…! We seek poverty reduction policies that revert the violations of the RTH. A campaign for the RTH care gives us the possibility of advancing our political agenda that strives for equity and justice and thus strives for structural changes behind the social, economic and political determinants of health. The challenge is to now disseminate these concepts to a wider public that live in countries that have signed covenants that call for the respect of the right to health.
26. We are no longer going to go to beg for changes to be implemented; we are now going to demand them based on existing international law clauses already enforceable in most of the countries where we work. Disseminating this concept is in itself empowering and is part and parcel of we are all called upon to do.
27. We nevertheless call on all readers for vigilance. The forces of status-quo are hijacking the concept of the RTH using it as a moral-imperative-tool only –indeed a soft imperative. We call on all readers to see and use the RTH as a political-imperative. The HRBAP should be used to empower claim holders and duty bearers. The HRBAP and the RTH call on us to launch a wide social mobilization movement.
28. We have to overcome the culture of silence and apathy about the HR violations in health we all know are happening. This, because HR and the RTH will never be given to poor, marginalized, discriminated and indigenous persons. Repeat, rights are never given, they have to be taken! And this is what we all need to attempt to do. Herein lies the challenge.
What we ought to be doing
27.The ‘Right to Health’ framework provides us with an internationally agreed-upon consensus structure, based on which a strong argument can be advanced. However, within this broad framework, it is perhaps, in a first phase, advisable to start with a focus on the ‘Right to Health Care’ as an urgent issue in the context of weakening health systems in many countries; this issue of access to quality health care can be, to a significant extent, acted-upon from within the health sector and still is a strong step towards economic and social justice. This, of course, requires broadening our vision of health care to a vision that includes, not only the entire range of preventive, promotive and curative health services, but also services like those that are nutrition-related, those that ensure drinking water quality and adequate health-related education and information systems, i.e., all the activities carried out with the primary and express purpose of improving health. It does not need to be emphasised that specific important aspects of this Right such as women’s right to health care, children’s health care rights, mental health rights, health care rights of HIV and AIDS-affected persons, workers’ health rights, the right to essential drugs, etc. need to be woven into what we ought to do thus bringing different branches of the global health movement into a broad coalition working for public health systems.
28.At the same time, we need to document and push for changes in the key wider determinants of health; also denouncing and acting upon the existing and new adverse policies that are having negative impacts on health. These should be identified at the country level and taken up as needed. This focus on health care should then be broadened in a subsequent phase.
29.Launching this kind of work with a new focus will involve organizational work, making alliances, spreading relevant ad-hoc information, carrying out extensive education, denouncing and monitoring the whole process of health care delivery.
Possible organisational collaboration
30.The United Nations Special Rapporteur on the Right to Health is entrusted with the responsibility of reviewing the status of implementation of this right the world over. He has shown interest in the idea of such a global Campaign. WHO has a division dealing with Ethics and Human Rights which needs to be approached regardless of present prospects of a partnership with them in this work. There are persons in other divisions of WHO such as the Poverty and Health Policies Division that have already shown a willingness to support this kind of work. Given the need to shift the focus of WHO towards a Rights-based approach and given its global potential to influence national health systems, WHO will need to be an important target of our networking. Most countries have National Human Rights Commissions or official bodies that can be involved, to varying extents, in monitoring the Right to Health. Human rights groups have the potential to take interest in this issue, especially in the context of issues like access to care for HIV and AIDS-affected persons. Of course, the People’s Health Movement members will need to take the lead within and among countries where they work thus involving a yet broader range of civil society organisations in our network including women’s organisations, coalitions of HIV and AIDS-affected persons, trade unions of health sector personnel, people’s movements, etc.
Suggested broad picture to launch a global campaign for the RTH care
31.To move towards implementing a campaign on this issue, we here propose a sequence of activities.
Preparatory phase
The following should be attempted:
Creation of a broad consensus on the idea of a RTH care campaign, involving as many as possible coalitions and networks so as to engage them in refining the strategy and developing the concept further. A global coordination committee should be formed to give overall guidance to the campaign.
Identification of specific groups that will take regional responsibilities in order to convene campaign activities in all regions of the world. If possible, at least one consultation within each region to discuss the campaign will have to be held. The issue of fund-raising for the campaign will be discussed with them as well.
Formation of a ‘Core Campaign Team’ of about 6-10 organizations or individuals who are driven by the vision and are willing to commit quality time to travel internationally. This team will actively support the regional organizers and will lead the international networking, fund-raising and advocacy work for the campaign, in fact, acting as its global ‘secretariat’.
Identification of short and long-term sources of funding for the various aspects of the campaign, at regional and global level.
Based on a shared framework, reaching of a clear understanding with key strategic allies –such as WHO and the Special Rapporteur on the Right to Health– to ensure their ownership and involvement in the campaign throughout the process. An agreed-upon mechanism for regular consultation with these allies will be set up.
Completion of guidelines for the ensuing preparation of status papers on ‘The State of the Right to Health’ in each country.
Discussion and planning of the next edition of the Global Health Watch that will assess, analyse and suggest lines of action to achieve the ‘Right to Health’ at global and regional level.
32.This phase will culminate in a restricted consultation in which the developments so far will be reviewed and plans made for the next phase of the campaign.
Documentation and analysis phase
During this period, country, regional and global reports will be prepared as follows:
Country papers or reports on the Status of Right to Health Care will be completed in the countries of at least two regions; in the other regions, the process will be started and brought to as an advanced stage as possible. Not all countries may be able to prepare these reports with comparable levels of detail, much depending on the capacities of the respective country teams identified with PHM help and the actual availability of information. Options are as follows:
Full blown Country Reports: These will be the most extensive and will analyse all or most aspects of the health system in the country and report on their current status with facts and figures, documenting why and how General Comment 14 has (not) been fulfilled five years after its adoption (within the framework of ‘progressive realization of the right to health’).
Country Status Papers: These will be less detailed and may not cover all components of the health sector, but will be based on country level information and statistics that bring out major health system gaps.
Country Overviews: These will only contain a listing of major issues of concern from the Right to Health perspective (e.g., declining health budgets, unregulated privatization, imposition of user fees, dismantling of the social security system). Some facts and figures will be presented. These country overviews will be prepared where detailed and reliable country level information is not available or the local group’s capacity is limited.
33.The aim is that about 50 countries will prepare these country reports or status papers –a minimum of 5 in each region.
The Global Health Watch Report chapter on the Right to Health will be drafted; it will focus on how the various global agencies and actors are infringing or opposing the Right to Health in different ways: the WTO through its patent regimes, the WB, the IMF and other international agencies through their lending and granting procedures; the MDGs focusing on outputs that foster vertical approaches rather than emphasizing human rights-based processes. It will also focus on the minimum obligations developed countries have to contribute to health development in poorer countries, to stop the Northward migration of health professionals and other such issues.
34.This phase culminates with the concrete planning of Regional Assemblies on the Right to Health in all regions of the world: Dates, venues, financial arrangements, major agenda contents and organising agencies will be identified and given concrete mandates. For this, a pre-planning meeting to finalise the program of these regional assemblies may be held during the 2006 WHA.
Regional Assemblies and subsequent action phase
Sequential regional assemblies on the Right to Health will be held in all regions of the world: one assembly in each of the regions. These will be co-organised by WHO, the Special Rapporteur and the People’s Health Movement and will be attended by national health officials, national human rights committees and PHM, as well as other health and human rights activists. Available country reports/country performance report cards on the Right to Health will be presented and discussed. This will be complemented by a regional analysis paper in each region, dealing with how international macro factors and global agencies affect the Right to Health in the region. These assemblies will attract wide media coverage as much as coverage by the media within each country involved should be assured. Action plans to implement the Right to Health will be drawn, discussed and presented in the second half of the assemblies. (For some suggestions of the content of such a plan see below)
This series of regional assemblies may culminate in some kind of a resolution being proposed for adoption at, say, the World Health Assembly in Geneva in 2007 or 2008; such a resolution will call for time-bound, complete implementation of the Right to Health and will put in place mechanisms for monitoring and redressal of this right in all countries of the world; it will also appeal for an end to all forms of violations of this right based on clearly defined standards in the CESCR’s General Comment 14. Partner organisations will also use this as a concrete opportunity to draw-in many more organisations into the network, to dialogue with their country governments, to engage with national human rights bodies and to build a consensus on the need to end violations of health rights in their various forms, as well as to reverse policies responsible for such violations.
Finalisation of the Global Health Watch report on the Right to Health is envisioned for April 2007. The same could include summaries of all the regional analysis papers and a one-page standardized abstract of each of the country Right to Health reports, i.e., country performance report cards on the Right to Health.
Preparation of a ‘Global Action Plan on the Right to Health’. Such a document will, with facts and figures, convincingly show how quality essential health services could be made available NOW to every human being on earth provided certain key reallocation of priorities and resources (transferred from rich to poor countries) are enacted, and provided that trade and patent regimes are changed to benefit countries that have been impoverished, as well as internal and external changes are made in relevant economic policies so as to allow an increased flow of resources to the social sector, allowing for a more rational reorganization of national health systems. This Global assessment will be accompanied by detailed, practical recommendations for the countries in each region; these may be appended as a compendium of specific recommendations for individual countries to consider and tale up.
Provided governments accept the major points suggested during the regional assemblies, the 2007 or 2008 World Health Assembly will be asked to adopt a ‘Declaration on the Right to Health for All’ for implementation by member countries, The same will have time-bound, specific and monitorable goals and contain the basic principles of a bottom-up health sector reform. Some of the primary shifts likely to be demanded will be moving from a vertical focus on programs to a comprehensive health systems approach; from the existing commercialized and privatized health care sector, to universal access through publicly managed health systems; from a meager flow of health resources from rich to poor countries to a more dependable, long-term flow of such resources –including the issues of patents, development assistance and the brain drain in the sector. The aim will be to sponsor effective community involvement and monitoring in health thus operationalising the Right to Health. A Universal Access to Comprehensive Health Care will be endorsed as an overarching principle, together with a related call for definitive changes in the global trade and patents regime as it affects health, and a shift in policies of all the international agencies working in the health sector towards a human rights-based approach to health planning.
Some possible outcomes of such a campaign
35.One can foresee the following scenario:
-An increased awareness in civil society and an explicit recognition by states of the Right to Health Care at country level in a large number of countries.
-The formation of health rights ‘watch’ or monitoring bodies –with civil society participation in several countries.
-Active involvement in Health rights issues of national human rights commissions or other similar bodies in several countries –all in the framework of GC 14.
-A clearer delineation of what ‘health rights’ are at both global and country level.
-A concrete interpretation of GC 14 by the Special Rapporteur on the Right to Health, in a form that can be used for monitoring of and advocacy for health rights.
-The identification and recognition of the actual concrete steps needed to actually operationalise health rights.
-The establishment of strong links among the different constituencies fighting for the right to health, i.e., women’s and reproductive health rights, children’s health rights, the health rights of HIV and AIDS affected persons, mental health care rights, the health rights of disabled persons –all within the same overarching framework of rights. All these will provide the basis for a ‘grand alliance’ between all the movements working for these specific rights so that all demand comprehensive, quality health care systems for all with special attention given to those that have special needs.
-The highlighting of key global processes that are infringing on the Right to Health Care (such as those depicted above plus the impact of structural adjustment on health budgets and inappropriate development assistance –ODA).
-The posting of concrete demands regarding global governance and advocacy in front of a few key global agencies (e.g., WTO, WB, FMI) that have an inordinate influence on the issues at stake.
-Bringing the Right to Health into the global health agenda and making it a reference point in the global health discourse, as well as asserting that the MDGs or any other vertical approaches give way (or be the entry point) to processes that make the health system equitable and that give access to comprehensive health care to the neediest. This can only be done by posing time-bound, achievable Right to Health process goals at global and national levels.
-The opposition to the unregulated, commercialised health care model that departs from the premise that health care is a commodity with the exception of some subsidised care for the poor, and the bringing back of the principle of ‘universal access to health care’ as a central goal, with a better paid, better motivated, well trained and accountable health manpower together with an active community involvement based on the rights approach.
-The preparation of a ‘Global Action Plan on Right to Health’ which will broadly present in facts and figures how quality essential health services can be made available to every human being NOW by providing the basis for more proactive international advocacy campaigns, and country and decentralised action plans on the Right to Health.
-The completion of the Declaration on the ‘Right to Health for All’ that commits governments and international agencies to the goal of universal access to health care in a rights-based framework.
36.Some shift in the focus of WHO towards the Human Rights-based Approach to Health is, finally, needed: a shift that puts universal access systems at the center and that strengthens a group inside WHO that will continue to work and provide leadership on this work.
A few conceptual and strategic points
38.Many of the conceptual aspects of the process being proposed will need to be developed through discussion and debate. Here are just a few summary points as an input to the discussion we now want to foster.
The campaign will initially focus on the Right to Health Care, while drawing from the wider Right to Health perspective.
The campaign will challenge the commoditization of health, asserting the inalienable role of the state in public health systems with the public at the center.
The campaign makes health rights operational and thus requires demanding specific commitments and norms that provide measurable parameters for the assessment/monitoring and for the enforcement of redressal mechanisms. (These absolutely need to be accompanied by active civil society and claim holders mobilization).
The campaign builds a broad strategic alliance involving various special health rights movements that already (or not yet) claim the Right to Health Care as a key human right.
The campaign is deeply rooted in national initiatives, yet also addresses key global processes and counters powerful strategic opponents.
The campaign vies for the ‘central ground’ in the health discourse, and engages major actors making them take a stand on the Right to Health.
The campaign represents a strategy of resistance today and offers a whole new alternative vision for tomorrow.
The campaign will be used to shift the discourse from the preoccupation with vertical programmes and privatisation-oriented measures to focusing more on widespread denial and violations of the Right to Health, on demanding a global consensus on the implementation of this right, and on asking that all programmes and measures now be critically evaluated according to the tenets of Health Rights.
What may be realistically achieved through the proposed process?
39.We have no illusion that systematically raising the issue of the ‘Right to Health’ will by itself lead to an actual complete implementation of this right in countries across the globe. The universal provision of even basic health services involves major budgetary, operational and systemic changes have to happen; in addition to shifting to a rights-based framework, major political and legal re-orientations are thus needed –and such major changes cannot be expected to happen in full in the near future, given the political economy of health care in most countries of the world today.
40.However, we can expect and can work on a number of more achievable objectives that can take us towards the larger Human Rights goal. Some of these ‘achievables’ to be considered in the campaign are: the explicit recognition of the Right to Health Care at country level; the formation, in some countries, of health rights monitoring bodies with civil society participation; a clearer delineation of health rights at both global and country level; the shifting of the focus of WHO towards health rights/ universal access systems and the strengthening of groups within WHO that will work along these lines; the bringing of the Right to Health Care more into the global agenda thus making it a central reference point in the global health discourse.
41.Finally, an example of what could be done in the longer run to achieve the RTH comes to us from India where they have drafted a National RTH Plan with the following characteristics: AVAILABLE FROM THE AUTHORS.
Abhay Shukla and Claudio Schuftan
abhayshukla1@gmail.com
schuftan@gmail.com